Marc Darrow MD,JD

We do get many emails about ankle pain. Some people write that they are on a waiting list for an ankle fusion, sometimes one, sometimes both ankles, and while they are waiting, they want to know if stem cell therapy can be an option. Others write that the are bone on bone and have lost all the cartilage in their ankle, can we help?

Treatment options for advanced ankle osteoarthritis

A study published in March 2019 (1) discusses the problem orthopedists and surgeons have in presenting treatment options to their patients with advanced ankle osteoarthritis. As many doctors and patients are aware, ankle osteoarthritis treatment protocols have no real guideline recommendations of its own. Researchers say most doctors treat an ankle problem as they would treat a knee or hip and follow hip or knee treatment protocols when treating the ankle. Is this really such a bad thing?

It is when you consider that these are the same guidelines of conservative care protocols that ultimately lead to patient pain management programs until such time that the knee or hip can be ultimately replaced. The difference in treating an ankle like a hip or an ankle like a knee is that doctors feel that if conservative care options do not work for knee or hip osteoarthritis, there is a reasonably reliable surgical option in total joint replacement. The same reasonably reliable surgical option, researchers suggests, may not be available for ankle replacement.

ankle osteoarthritis

The risks and rewards of ankle arthrodesis or ankle fusion and total ankle replacement.

Recent research in the British medical bulletin (2) discuss the risks and rewards of ankle arthrodesis or ankle fusion and total ankle replacement.

  • Total ankle replacement while an accepted treatment for end-stage ankle osteoarthritis has a higher need for revision surgery than ankle fusion.
  • While surgical outcome results are gradually improving, Total ankle replacement cannot yet be recommended for the routine management of ankle osteoarthritis.

Younger than 65 and obese. Two main factors for total ankle replacement

A February 2021 study (3) found that increased risk for total ankle replacement failure was seen more in patients under the age of 65, as opposed to older patients who did not have increased risk, and in patients who were obese as opposed to normal weight patients.

  • Failure of total ankle replacement was defined as a patient having to then undergo revision total ankle replacement or ankle fusion procedures.

The more ankle replacements, the more failures

In the medical journal Foot & ankle specialist, Duke university doctors wrote as the number of total ankle replacements performed has risen, so has the need for a specialty medicine to perform secondary or revision surgery to fix the primary ankle replacement failure.(4)

These are the people studied in this report:

  • 193 patients
  • The majority of the revision surgeries had:
    • hardware component loosening, frequently of the talar component (38%).
    • In the cases that were revised to an ankle fusion, 81% fused after their first fusion procedure.
    • The overall complication rate was 18.2%, whereas the overall nonunion rate was 10.6%.

Surgery can cause pain and complication in healthy ankle tissue

Research in the Journal of Foot and Ankle Surgery (5) examined why a patient will still have chronic ankle pain following ankle replacement:

The researchers suggested:

  • “Total ankle replacement studies have focused on reporting complications that are directly observed clinically or radiographically, including wound problems, technical errors, implant loosening, subsidence, infection, bone fractures, and heterotopic ossification. However, patients can still experience unresolved pain even when these problems have been ruled out.”
  • The researchers then initiated a study to more clearly define the relative risk of injury to the anatomic structures in the posterior (rear) ankle during total ankle replacement. They found:
    • High rates of posterior structural injury from the surgery was found.
    • Pins inserted during the surgery represented a high risk of damage to the tibial nerve posteromedial tendinous structures, in particular, the flexor digitorum longus tendon.
    • The proximal lateral pins were highly likely to encounter the Achilles tendon and the sural nerve.
  • The researchers concluded: “Our results support our hypothesis that the tibial neurovascular structures are at the greatest risk when preparing for and completing the bony resection, particularly with the medial and proximal cuts. Posterior ankle soft tissue structure injuries can occur during implantation but currently with unknown frequency and undetermined significance. Further study of posterior structural injuries could result in a more informed approach to post-total ankle replacement complications and management.”

Is an ankle fusion better than an ankle replacement? Is the ankle replacement better?

This is another question I am often asked and again I reply that if you have a good range of motion, even through pain, you would likely be a good candidate for stem cell therapy.

But what if your mind is set on surgery. Which is better? Here is an opinion from the Department of Orthopaedic Surgery, Tulane University School of Medicine published in the research Janaury 2021. (6)

“There (is little) data comparing complications between ankle arthrodesis (fusion) versus total ankle arthroplasty (replacement) for operative management of primary osteoarthritis (osteoarthritis). This study aimed to compare outcomes following ankle arthrodesis (fusion) versus total ankle arthroplasty (replacement) for primary ankle osteoarthritis using a large patient database.

Results: A total of 1136 (67%) patients received ankle arthrodesis (fusion) and 584 (33%) patients underwent total ankle arthroplasty (replacement). Patients that received ankle arthrodesis (fusion) exhibited significantly higher rates of at least one common joint complication at 90 days, 1 year, and 2 years postoperatively. This included higher rates of adjacent fusion or osteotomy procedures, periprosthetic fractures, and hardware removal at each postoperative follow-up. Rates of prosthetic joint infection were comparable at 2 years postoperatively.

Conclusion: The ankle arthrodesis (fusion) cohort exhibited higher rates of postoperative joint complications in the short and medium-term, namely, subsequent fusions or osteotomies, periprosthetic fractures, and hardware removal.”

A May 2021 study (7) suggested total ankle replacement showed significantly greater post-operative range of motion than ankle fusion  but no other differences in other patient-reported outcome scores. Patients undergoing total ankle replacement showed higher post-operative SF-36 (36 question health status survey). The total complication rate was similar between the two procedures including the incidence of re-operations.

Conclusion: While total ankle replacement and ankle fusion showed no differences in most post-operative functional outcomes, patients undergoing total ankle replacement show better health-related quality of life than ankle fusion. The study found no evidence to suggest that total ankle replacement carries a higher risk of complications and re-operations compared to ankle fusion.

What Are Stem Cells?

Stem Cells are a unique type of cells that have the ability to help the body repair any tissues that are damaged. For example, if you have a foot injury then stem cells can help repair the tissues.

The research on stem cell therapy for ankle osteoarthritis

Many people call our office and they wan to know about stem cell therapy. Many times they call our office looking for advice on getting stem cell therapy during an ankle procedure. Specifically, if this will make the surgical outcome better. There always has to be realistic expectation of what stem cells can do for advanced ankle osteoarthritis, even when stem cells are administered during a surgery.

An August 2021 study (8) evaluated the long-term follow-ups in patients undergoing a one-step procedure of debridement (removing dead tissue and debris) and bone marrow aspirate concentrate seeded in situ (at the site of the degenerative disease in the ankle) for the treatment of osteochondral lesions of the talus in ankles affected by osteoarthritis, documenting the duration of the clinical benefit and its efficacy in postponing end-stage procedures.

  • Results: Almost two out of the three patients in the study were satisfied with results. Failure rate was 33.3%.
  • Older patients and those with more complex cases requiring previous or combined surgeries had lower outcomes, as well as those affected by grade 3 osteoarthritis, who experienced a high failure rate of 71.4%.

This is why Stem Cell Therapy is more optimal than doing ankle replacement

Stem Cell Treatment Work Without The surgery

At the Darrow Stem Cell Institute, our research,  “Treatment of Ankle Osteoarthritis with Bone Marrow Concentrate Injections,” is awaiting publication. There have been studies already published that suggest bone marrow-derived stem cells are an effective treatment for ankle osteoarthritis patients.

December 2016 research in the Journal of experimental orthopedics from doctors at the Steadman Philippon Research Institute (9) reviewed the research in the treatment of ankle osteoarthritis with bone marrow derived stem cells.

  • The goal of this study was to review outcomes of bone marrow aspirate concentrate (bone marrow-derived stem cells) for the treatment of chondral (cartilage) defects and osteoarthritis of the talus of the ankle.

The researchers noted that there is not much research (at the time of this paper’s writing). . . Nonetheless, the evidence available showed varying degrees of beneficial results of bone marrow derived stem cell therapy for the treatment of ankle cartilage defects.

  • The researchers hypothesized that bone marrow aspirate concentrate may be useful in regeneration of tissue, enhancing the quality of cartilage repair. As a result, BMAC promotes a potentially healthy environment for hyaline cartilage growth and repair.

Research cited:

  • A 2009 study published in Clinical Orthopaedics and Related Research, reported that 94 % of patients returned to low impact sports activity at an average 4.4 months after bone marrow aspirate transplantation and 77 % of patients returned to high impact sports activity at an average 11.3 months. (10)
  • The same researchers in 2013 reported that 73 % of the 36 patients playing sports before surgery were able to return to sports. They also reported that 22 % of these 36 patients were able to return to sport, but at a lower level than before surgery. (11)
  • A 2011 study reported that 95 % of patients who had undergone bone marrow concentrate treatments returned to their pre-symptom level of sporting activity at an average 13 weeks.(12)

A 2016 report in the Journal of experimental orthopaedics (13) examined ways to save the ankle from fusion and replacement. In this study, Italian researchers discussed joint saving procedures such as:

  • Surgical procedures such as Arthroscopic debridement, arthrodiastasis, and osteotomy are the current joint sparing procedures, but, in the available studies, controversial results were achieved
  • Better results for patients they speculated could be achieved with Mesenchymal stem cells (MSCs). They write that stem cells may be a good solution to prevent or reverse ankle degeneration, due to their immunomodulatory features (able to control the catabolic joint environment) and their regenerative osteochondral capabilities (able to treat the chondral defects).

In research from Korea, doctors found that after ankle surgery, such as osteotomy, ankle bones treated with bone marrow stem cell injections repaired significantly better. than those not treated (14) My question is always, why not try it before the surgery?

A heavily cited and received 2015 study showed that stem cell treatments were able to regrow cartilage in ankles significant enough to improve function and pain levels in selected patients. Walking distances were shown to dramatically improve in the patient group.(15)

In a post-surgical study from December 2018, (16) researchers found the injection of bone marrow mesenchymal stem cells could improve the repair process of the osteonecrosis.

Do you have questions? Ask Dr. Darrow


A leading provider of stem cell therapy, platelet rich plasma and prolotherapy

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

Article citations:

1 Paterson KL, Gates L. Clinical Assessment and Management of Foot and Ankle Osteoarthritis: A Review of Current Evidence and Focus on Pharmacological Treatment. Drugs & aging. 2019 Jan 25:1-9.
2 Maffulli N, Longo UG, Locher J, Romeo G, Salvatore G, Denaro V. Outcome of ankle arthrodesis and ankle prosthesis: a review of the current status. British Medical Bulletin. 2017 Nov 23:1-22.
3 Suh DH, Han K, Lee JW, Kim HJ, Kim B, Koo BM, Kim HK, Choi GW. Risk factors associated with failure of total ankle arthroplasty: a nationwide cohort study. Scientific Reports. 2021 Feb 3;11(1):1-9.
4 Gross C, Erickson BJ, Adams SB, Parekh SG. Ankle arthrodesis after failed total ankle replacement: a systematic review of the literature. Foot & ankle specialist. 2015 Apr;8(2):143-51.
5. Reb CW, McAlister JE, Hyer CF, Berlet GC. Posterior Ankle Structure Injury During Total Ankle Replacement. J Foot Ankle Surg. 2016 Jun 9.
6 Ross BJ, Savage-Elliott I, Wu VJ, Rodriguez RF. Complications Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Primary Ankle Osteoarthritis. Foot Ankle Spec. 2021 Jan 20:1938640020987741. doi: 10.1177/1938640020987741. Epub ahead of print. PMID: 33472419.
7 Fanelli D, Mercurio M, Castioni D, Sanzo V, Gasparini G, Galasso O. End-stage ankle osteoarthritis: arthroplasty offers better quality of life than arthrodesis with similar complication and re-operation rates—an updated meta-analysis of comparative studies. International Orthopaedics. 2021 May 4:1-5.
8 Vannini F, Filardo G, Altamura SA, Di Quattro E, Ramponi L, Buda R, Giannini S, Faldini C. Bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in ankle osteoarthritis: satisfactory clinical outcome at 10 years. Knee Surgery, Sports Traumatology, Arthroscopy. 2021 Feb 19:1-7.
9 Chahla J, Cinque ME, Schon JM, et al. Bone marrow aspirate concentrate for the treatment of osteochondral lesions of the talus: a systematic review of outcomes. Journal of Experimental Orthopaedics. 2016;3:33. doi:10.1186/s40634-016-0069-x.
10 Giannini S, Buda R, Vannini F, Cavallo M, Grigolo B. One-step Bone Marrow-derived Cell Transplantation in Talar Osteochondral Lesions. Clinical Orthopaedics and Related Research. 2009;467(12):3307-3320. doi:10.1007/s11999-009-0885-8.
11 Giannini S, Buda R, Battaglia M, Cavallo M, Ruffilli A, Ramponi L, Pagliazzi G, Vannini F. One-step repair in talar osteochondral lesions: 4-year clinical results and t2-mapping capability in outcome prediction. The American journal of sports medicine. 2013 Mar;41(3):511-8.
12 Kennedy JG, Murawski CD. The Treatment of Osteochondral Lesions of the Talus with Autologous Osteochondral Transplantation and Bone Marrow Aspirate Concentrate: Surgical Technique. Cartilage. 2011 Oct;2(4):327-36. doi: 10.1177/1947603511400726. PMID: 26069591; PMCID: PMC4297142.
13 Castagnini F, Pellegrini C, Perazzo L, Vannini F, Buda R. J Exp Orthop. 2016 Dec;3(1):3. doi: 10.1186/s40634-016-0038-4. Epub 2016 Jan 15. Joint sparing treatments in early ankle osteoarthritis: current procedures and future perspectives.
14 Kim YS, Lee M, Koh YG. Additional mesenchymal stem cell injection improves the outcomes of marrow stimulation combined with supramalleolar osteotomy in varus ankle osteoarthritis: short-term clinical results with second-look arthroscopic evaluation. Journal of Experimental Orthopaedics. 2016;3:12. doi:10.1186/s40634-016-0048-2.
15 Emadedin M, Ghorbani Liastani M, Fazeli R, et al.Long-Term Follow-up of Intra-articular Injection of Autologous Mesenchymal Stem Cells in Patients with Knee, Ankle, or Hip Osteoarthritis. Arch Iran Med. 2015 Jun;18(6):336-44. doi: 015186/AIM.003.
16 Hernigou P, Dubory A, Lachaniette CH, Khaled I, Chevallier N, Rouard H. Stem cell therapy in early post-traumatic talus osteonecrosis. International orthopaedics. 2018 Dec 1;42(12):2949-56.1767


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