Severe Varus Deformity Does Not Compromise Total Ankle Arthroplasty Outcomes, Study Finds

The findings from this recent study in the Journal of Foot and Ankle Surgery suggest that with appropriate adjunctive procedures and deformity correction strategies, severe varus alignment should not be considered a clear contraindication to modern TAA.

Key Takeaways

• Patients with severe varus deformity (≥15°) achieved clinical outcomes comparable to those with neutral or mild varus alignment following TAA.
• Severe deformities required significantly more concomitant corrective procedures, particularly lateral sliding calcaneal osteotomy and first tarsometatarsal arthrodesis.
• Complication, osteolysis, and reoperation rates were similar across all deformity groups, supporting the feasibility of TAA in carefully selected patients with substantial coronal plane malalignment.

Study Examines the Impact of Varus Severity on TAA Outcomes

In a retrospective Level III study published in the Journal of Foot & Ankle Surgery, Kim and colleagues evaluated whether the severity of preoperative varus deformity influences clinical and radiographic outcomes after total ankle arthrolplasty (TAA).¹

The study included 190 total ankle arthroplasties performed between 2014 and 2023 using a cementless, 3-component mobile-bearing prosthesis. Patients were categorized into 3 groups based on preoperative coronal alignment: neutral (<5°), mild-to-moderate varus (5° to <15°), and severe varus (≥15°).¹

Historically, severe varus malalignment has been viewed as a technical challenge that may increase the risk of implant malposition, instability, and early failure. However, advances in surgical planning and adjunctive reconstruction have expanded the indications for TAA in complex deformity cases.¹

Significant Functional Improvements Across All Groups

Regardless of deformity severity, patients experienced substantial improvements in pain and function following surgery.

American Orthopaedic Foot & Ankle Society (AOFAS) scores improved from approximately 46–48 preoperatively to 87–91 at final follow-up. Similarly, Visual Analog Scale (VAS) pain scores decreased from roughly 7 points before surgery to approximately 1.2–1.3 points postoperatively.¹

Investigators also reported successful radiographic correction of coronal plane alignment in all three groups, demonstrating that even severe deformities could be effectively addressed with contemporary surgical techniques.

Severe Varus Cases Required More Adjunctive Reconstruction

While outcomes were comparable, patients with severe varus deformity frequently required additional procedures to achieve appropriate alignment and balance.

The severe varus cohort underwent significantly higher rates of concomitant reconstruction, particularly lateral sliding calcaneal osteotomy and first tarsometatarsal arthrodesis. These procedures were used to address hindfoot and medial column pathology contributing to overall deformity.¹

The findings underscore the importance of viewing TAA in severe varus ankles as a comprehensive reconstructive procedure rather than a simple implant operation.

Comparable Complication and Reoperation Rates

Despite the greater surgical complexity of severe varus cases, complication rates were not significantly different among the 3 groups.

Rates of osteolysis, postoperative complications, and reoperations remained comparable regardless of preoperative alignment severity. These results challenge longstanding concerns that severe varus deformity inherently increases the risk of failure following TAA.¹

Clinical Perspective for Foot and Ankle Surgeons

For podiatric surgeons, the study adds to a growing body of evidence suggesting that successful TAA depends less on the magnitude of deformity itself and more on the surgeon's ability to achieve durable correction and balanced alignment.¹

The findings support a modern reconstructive approach in which concomitant procedures are strategically employed to restore hindfoot alignment, redistribute load, and optimize implant positioning. While severe varus deformity may increase surgical complexity and operative planning requirements, it does not appear to compromise mid-term outcomes when appropriately addressed.¹

As TAA indications continue to expand, these results may help reassure surgeons and patients that severe coronal plane deformity alone should not absolutely preclude consideration of ankle replacement.

Reference

1. Kim WS, Benedicta S, Lim JW, Jung HG. Impact of preoperative varus deformity severity on clinical and radiographic outcomes following total ankle arthroplasty. J Foot Ankle Surg. Published online June 7, 2026. doi:10.1053/j.jfas.2026.06.005.