Talar prosthetic replacement and talus-sacrificing hindfoot arthrodesis for advanced talar avascular necrosis in adults: a systematic review

Abstract Background Once avascular necrosis (AVN) has collapsed the talar body, surgeons must choose between prosthetic replacement, which preserves ankle motion, and talus-sacrificing hindfoot arthrodesis, which does not. No previous review has examined both within a single evidence frame. This review aimed to establish outcome benchmarks for each strategy and to pool outcomes where sufficient independent cohorts were available. Methods PubMed/MEDLINE, Embase, Scopus, Web of Science and Cochrane CENTRAL were searched from inception to [date], supplemented by a further database search. Studies of at least five adults with advanced talar AVN treated with talar body or total talar prosthesis, or with tibiotalocalcaneal or tibiocalcaneal arthrodesis, with at least 12 months of follow-up were eligible. Serial reports of the same patients were counted once, and studies combining AVN with other indications without separate reporting were treated as non-contributory. Methodological limitations were assessed descriptively. Outcomes reported by at least four independent cohorts were pooled with a random-effects generalised linear mixed model. Results Fourteen reports describing 11 studies were eligible but represented seven independent cohorts: three of prosthetic replacement (92 ankles) and four of arthrodesis (58 ankles). All were retrospective and six were uncontrolled case series. The pooled union rate after arthrodesis was 90.4% (95% confidence interval 67.5% to > 99.9%), although leave-one-out estimates ranged from 79.5% to 100% and the 95% prediction interval spanned 2.8% to > 99.9%. Pain and function improved in all three prosthesis cohorts, but only one reported reoperation as an event count. One matched comparative study reported 10-year survivorship of 95.8% with prosthesis and 70.8% with arthrodesis. Conclusions The available evidence is too sparse and heterogeneous to establish the superiority of either strategy, and its apparent volume overstates the number of distinct cohorts studied. Treatment selection should be guided by residual bone stock, soft-tissue status and implant availability. Comparative studies reporting reoperation-free survival by diagnosis are needed. Systematic review registration: PROSPERO CRD420261507894.