
==== Front
J Orthop Surg Res
J Orthop Surg Res
Journal of Orthopaedic Surgery and Research
1749-799X
BioMed Central London

39238021
5045
10.1186/s13018-024-05045-8
Research Article
Female sex as a negative predictor of outcomes of ankle arthrodesis: a retrospective comparative monocentric study
Fischer Sebastian sebastian.fischer@bgu-frankfurt.de

1
Neun Oliver 1
Rüsseler Miriam 2
Herrmann Eva 3
Schippers Philipp 4
Münzberg Matthias 5
Hoffmann Reinhard 5
1 https://ror.org/04kt7f841 grid.491655.a 0000 0004 0635 8919 Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany
2 https://ror.org/04cvxnb49 grid.7839.5 0000 0004 1936 9721 Institute for Medical education and clinical simulation, Goethe University Frankfurt, 60590 Frankfurt, Germany
3 https://ror.org/04cvxnb49 grid.7839.5 0000 0004 1936 9721 Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, 60590 Frankfurt, Germany
4 grid.410607.4 Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg, University Mainz, 55131 Mainz, Germany
5 https://ror.org/04kt7f841 grid.491655.a 0000 0004 0635 8919 Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389 Frankfurt, Germany
6 9 2024
6 9 2024
2024
19 5457 6 2024
1 9 2024
© The Author(s) 2024
2024
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Background

End-stage post-traumatic osteoarthritis of the ankle joint may require arthrodesis if conservative treatment fails and a decision against total ankle replacement is made. We aimed to compare the sex-specific differences in outcomes and objectify them using validated specific scores.

Methods

Between 2010 and 2021, 221 patients underwent ankle arthrodesis at our institution, including 143 men (MAA) and 78 women (FAA). In addition to demographic data, the aetiology of osteoarthritis, the Foot Function Index (FFI-D), the Olerud-Molander Score (OMAS), and the Short Form-12 questionnaire (SF-12) were collected in this monocentric study. The mean follow-up time was 5.8 years. End-stage osteoarthritis was mostly due to ankle fractures as a result of sprains, falls, and road traffic accidents.

Results

Post-operatively, the mean FFI-D for pain was 17.3 (MAA: 14.7; FAA 22.2) and 43.9 for function (MAA: 41.1; FAA 49.5); the mean OMAS was 58.2; and the mean SF-12 physical component score was 42.5. Women achieved significantly worse results in all scores; only the mental component summary of the SF-12 did not differ between the sexes (p > 0.05). Approximately 34% of women stated that the result in terms of gait pattern was worse than expected (MAA 16.1%; p < 0.05). Again, significantly more men stated that the result was better than expected (MAA: 48.3%; FAA: 31.5%, p < 0.05).

Conclusions

The fact that the clinical results were significantly worse in women after ankle arthrodesis should be considered when determining the indication. However, the expectations of men and women also need to be individually adjusted.

Keywords

Post-traumatic osteoarthritis
Ankle arthrodesis
Sex-specific differences
Trauma and orthopaedic research
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcBackground

End-stage post-traumatic osteoarthritis of the ankle joint represents a massive impairment in coping with everyday life. Arthrodesis may be indicated if conservative treatment, such as adaptation of footwear, physiotherapy, weight reduction, and non-steroidal anti-inflammatory drugs, fails, and a decision has been made against total ankle replacement.

Clinically, tibiotalar osteoarthritis is primarily characterised by a (sub)total loss of the joint space and an increasingly anterior translation of the talus with flattening of the talar dome with tibial and talar osteophytes. Varus deformities of the ankle are more common in this context than valgus deformities; however, both deformities commonly have clinical correlations starting with pain on exertion, followed by pain after exertion, and later pain at rest with a simultaneously objectifiable restricted range of motion of the tibiotalar joint [1]. Nevertheless, it is not always possible to draw the same conclusions from X-ray findings about the expected complaints. Age, constitution, and patient expectations play a vital role [2].

The influence of sex on arthrodesis remains unclear. As men are generally more likely to be found in physically demanding occupations and engage in comparatively more injury-prone sports, an accident-related physical impairment and arthrodesis of the ankle joint could also be expected to result in a different outcome [3, 4]; current study results are based on data from a male-dominated study population [5–7]. We, therefore, aimed to directly compare the clinical outcomes of men and women after tibiotalar arthrodesis using specific and validated scores.

Methods

From 2010 to 2021, 338 patients were screened for eligibility to participate in the study (Fig. 1). After assessment of the inclusion and exclusion criteria, 221 patients were included in this retrospective comparative monocentric study (143 males and 78 females, mean age: 64 years [range: 29–91 years]). The demographic data were equally distributed without significant differences (Table 1).

Fig. 1 Flow chart of the study

Table 1 Patient characteristics

Characteristic		Male AA (n = 143)	Female AA (n = 78)	All (n = 221)	p	
Age, years	Mean	64.15	62.73	63.67	0.409		
	SEM	1.02	1.33	0.81			
	Minimum	32.00	29.00	29.00			
	Maximum	91.00	86.00	91.00			
Follow-up (months)	Mean	72.23	64.15	69.48	0.157		
	SEM	3.35	4.53	2.70			
	Minimum	13.00	13.00	13.00			
	Maximum	152.00	145.00	152.00			
BMI, kg/m2	Mean	29.76	29.39	29.63	0.671		
	SEM	0.48	0.80	0.42			
	Minimum	20.10	18.60	18.60			
	Maximum	58.30	64.10	64.10			
Affected side, n (%)	Left	63 (44.10)	35 (44.87)	98 (44.34)	0.976		
	Right	80 (55.94)	43 (55.13)	123 (55.66)			
Smoker, n (%)	Yes	24 (16.78)	18 (23.07)	42 (19.00)	0.513		
	No	118 (82.52)	60 (76.93)	178 (80.55)			
	N/A	1 (0.69)	-	1 (0.45)			
Pre-existing conditions, n (%)	Associated metabolic syndrome	54 (37.76)	23 (31.51)	77 (35.65)	0.031	
	Rheumatism	3 (2.10)	4 (5.48)	7 (3.24)		
	Others	43 (30.07)	31 (42.47)	74 (34.26)		
	None	43 (30.07)	15 (20.55)	58 (26.85)		
AA, Ankle Arthrodesis; BMI, body mass index; SEM, standard error of the mean; N/A, not applicable

All patients underwent isolated tibiotalar arthrodesis for end-stage post-traumatic osteoarthritis of the ankle. Three surgeons with comparable expertise in this type of surgery were involved. The mean follow-up time for clinical outcomes was 5.8 years. All procedures were performed in accordance with the 1964 Declaration of Helsinki and its subsequent amendments. The ethics committee of the trial site approved this study (DRKS00034373).

Inclusion and exclusion criteria

Patients were at least 18 years old at the time of inclusion in the study; there was no age limit. Written informed consent was also required. Only patients with previous surgery at the study centre were included, and the indication for arthrodesis had to be due to end-stage post-traumatic osteoarthritis. Destruction of the ankle joint due to other causes such as rheumatic diseases or malignant bone neoplasms such as osteosarcoma were excluded.

Surgical procedure

All participants underwent isolated tibiotalar arthrodesis with preservation of the subtalar joint using an identical surgical procedure. There were many reasons for deciding against an arthroplasty, including insufficient bone stock, advanced varus or valgus malalignment, pronounced ligament instability or the patient’s wish not to undergo such a procedure. The decision to perform an ankle arthrodesis was based on the patient complaints and the objectifiable radiologic criteria for osteoarthritis. All procedures were performed under general anaesthesia or, less frequently, spinal anaesthesia, and a tourniquet was applied to the thigh.

Ankle fusion was performed via an anterior approach between the tibialis anterior and extensor hallucis longus tendons. Medial, lateral, and dorsal approaches were not performed.

The tibiotalar joint was then dissected via this approach, with the remaining residual cartilage removed and subchondral sclerosis resected. The interposition of autologous or allogeneic spongy bone was performed in < 10% of cases.

After preparing the joint, fusion was performed by inserting 2–3 converging cannulated screws (diameter 6.5–8 mm) or an anterior fusion plate. In addition to objectifiable criteria such as a reduced bone stock, the choice of procedure was largely influenced by the preference and experience of the respective surgeon. The ankle arthrodesis was performed so that the talus was neutral below the tibial plateau in both the coronal and sagittal planes, with a physiological valgus of the hindfoot of approximately 5°.

Rehabilitation protocol

The post-treatment scheme after ankle arthrodesis for all patients included wearing an orthotic boot (e.g. VACOped™, OPED GmbH, Valley/Oberlaindern, Germany) for 10–12 weeks and walking on forearm or armpit crutches. For the first 6 weeks, patients had to wear the boot 24 h a day and were only allowed to take it off for personal hygiene and physiotherapy, primarily involving manual lymph drainage and toe mobilisation. An X-ray check at 6 weeks post-operatively provided feedback regarding the gradual resumption of weight-bearing over a further 4–6 weeks. From this point onwards, the boot could be removed at night.

Subsequent computed tomography imaging, usually 12 weeks postoperatively, served as the final clearance to walk without the orthotic boot. All patients were prescribed orthopaedic adjustments to their everyday footwear, and the fitting of a roll-off sole was recommended. From this point onwards, the crutches could be omitted and the weight-bearing could be adjusted independently to the pain sensation.

Assessment methods

Demographic data such as age, body mass index (BMI), pre-existing conditions, and nicotine abuse were collected by sex and the underlying aetiology of osteoarthritis was recorded (Tables 1 and 2). In addition, after a mean follow-up of 5.8 years, the clinical outcome was objectified using the following specific and validated scores: Olerud and Molander Ankle Score (OMAS), the Short Form-12 questionnaire (SF-12) including the physical and mental summation scale, the Foot Function Index (FFI-D) in its validated German version, as well as the type and number of revisions during the follow-up examination (Table 3).

Table 2 Aetiology of underlying osteoarthrosis of the affected ankle

Predisposing factors and history, multiple answers		Male AA (n = 143)	Female AA (n = 78)	All (n = 221)	p	
Ankle fractures, n (%)	Yes	59 (41.26)	50 (64.10)	109 (49.32)	0.001		
	No	84 (58.74)	28 (35.90)	112 (50.68)			
Mechanism, n (%)	Distorsion	48 (33.57)	45 (57.69)	93 (42.08)	0.052		
	Fall from height	30 (20.98)	13 (16.66)	42 (19.00)			
	Traffic accident	28 (19.58)	13 (16.66)	41 (18.55)			
	Others	37 (25.87)	7 (8.97)	45 (20.36)			
Fractures of the talus, n (%)	Yes	3 (2.10)	6 (7.69)	9 (4.07)	0.397		
	No	140 (97.90)	72 (92.30)	212 (95.92)			
Fractures of the tibial plafond, n (%)	Yes	23 (16.08)	8 (10.26)	31 (14.02)	0.056		
	No	120 (83.92)	70 (89.74)	190 (85.98)			
Open fractures, n (%)	Yes	10 (6.99)	4 (5.13)	14 (6.33)	0.510		
	No	133 (93.01)	74 (94.87)	207 (93.67)			
	Gustilo Grade I	2 (1.40)	0 (0.00)	2 (0.90)			
	Gustilo Grade II	3 (2.10)	2 (2.56)	5 (2.26)			
	Gustilo Grade III	5 (3.50)	2 (2.56)	7 (3.16)			
Infections, bony or soft tissue, n (%)	Yes, postoperative	7 (4.90)	4 (5.12)	11 (4.98)	0.660		
	Yes, haematogenic	10 (6.99)	2 (2.56)	12 (5.43)			
	No	126 (88.11)	72 (92.32)	198 (89.59)			
Delayed union or non-union tibial, n (%)	Yes	24 (16.78)	13 (16.67)	37 (16.74)	0.851		
	No	119 (83.22)	65 (83.33)	189 (83.26)			
Chronic ankle instability, n (%)	Yes	32 (22.38)	16 (20.51)	48 (21.72)	0.759		
	No	111 (77.62)	62 (79.49)	173 (78.28)			
Deformities of the hind foot, n (%)	Varus deformity	34 (23.78)	12 (15.38)	46 (20.81)	0.008		
	Valgus deformity	8 (5.60)	1 (1.28)	9 (4.07)			
	No	101 (70.63)	65 (83.33)	166 (75.12)			
Primary arthrosis, n (%)	Yes	9 (6.29)	2 (2.56)	11 (4.98)	0.104		
	No	134 (93.71)	76 (97.43)	210 (95.02)			
Failed total ankle replacement, n (%)	Yes	5 (3.50)	4 (5.12)	10 (4.52)	0.493		
	No	138 (96.50)	74 (94.87)	211 (95.48)			
Neurological issue, n (%)	Yes	6 (4.20)	3 (3.84)	9 (4.07)	0.976		
	No	137 (95.80)	75 (96.15)	207 (95.93)			
AA, Ankle Arthrodesis

Table 3 Clinical outcomes with subgroups

Measurements		Male AA (n = 143)	Female AA (n = 78)	All (n = 221)	p	
FFI-D Functional Disability	Mean	41.11	49.52	43.96	0.003		
	SEM	1.61	2.35	1.36			
	Minimum	4.00	10.50	4.00			
	Maximum	83.50	89.00	89.00			
FFI-D Pain	Mean	14.72	22.21	17.27	< 0.001		
	SEM	1.08	1.85	0.98			
	Minimum	0.00	0.00	0.00			
	Maximum	57.00	60.00	60.00			
Olerud and Molander	Mean	62.08	50.55	58.16	< 0.001		
	SEM	1.99	2.86	1.67			
	Minimum	10.00	0.00	0.00			
	Maximum	100.00	95.00	100.00			
SF-12 (physical component summary)	Mean	43.82	39.91	42.49	0.009		
	SEM	0.86	1.21	0.71			
	Minimum	16.54	19.92	16.54			
	Maximum	61.22	56.80	61.22			
SF-12 (mental component summary)	Mean	51.54	50.15	51.07	0.363		
	SEM	0.85	1.32	0.72			
	Minimum	18.39	25.34	18.39			
	Maximum	65.78	71.03	71.03			
Number of operations until union, including fracture treatment, n	Mean	3.80	4.20	3.90	0.417		
	SEM	0.27	0.31	0.21			
	Minimum	1.00	1.00	1.00			
	Maximum	20.00	18.00	20.00			
Time from onset of symptoms to arthrodesis in months	Mean	240.55	207.25	227.80	0.300		
	SEM	21.27	21.87	15.58			
	Minimum	1.00	1.00	1.00			
	Maximum	780.00	648.00	780.00			
Complication, including revision surgery needed until union (multiple answers), n (%)*	Yes	9 (6.29)	7 (8.97)	16 (7.24)	0.384		
	No	134 (93.71)	71 (91.03)	205 (92.76)			
	Delayed union	3 (2.10)	2 (2.56)	5 (2.26)			
	Delayed wound healing	1 (0.69)	5 (6.41)	6 (2.71)			
Revision needed, n (%)	Infection	5 (3.50)	0 (0.00)	5 (2.26)			
Return to original profession, n (%)	Yes	52 (36.36)	24 (30.77)	76 (34.39)	0.732		
Retraining, part time, and pension, n (%)	Yes	75 (52.45)	43 (55.13)	118 (53.39)			
Permanently unable to work, n (%)	Yes	16 (11.189)	11 (14.10)	27 (12.22)			
AA, Ankle Arthrodesis; FFI-D, Foot Function Index in German version; SF-12, 12-Item Short Form Health Survey; SEM, standard error of the mean

Statistical analysis

The primary objective was to compare significant differences in outcomes between men and women after initial ankle arthrodesis using a representative number of patients to illustrate the validity of the included data with a mean follow-up of 5.8 years. A difference of 10 points in the Olerud-Molander score was regarded as an MCID (minimal clinically important difference). Previous monocentric studies with comparable questions had smaller populations [5, 8–10]. All statistical analyses were performed with SPSS v. 23 (IBM Dtl. GmbH, Ehningen, Germany). In addition, descriptive and exploratory statistical analyses were performed for the surveyed values, including within-group medians, means, minima and maxima, as well as standard error of the mean (SEM). An analysis of variance and Student’s t-test were used. The significance level was set at p < 0.05, with a study power of 0.8 and confidence interval of 95%.

Results

After a mean postoperative follow-up period of 69.5 months (range: 13–152 months), the mean FFI-D total score was 44.0 (MAA: 41.1; FAA: 49.5) and the mean OMAS-score was 58.2 (MAA: 62.1; FAA: 51.0; p < 0.05). The physical component summery scale of the SF-12 also differed significantly, with males showing values of 43.8; females, 39.9. Only the mental summation scale showed no significant difference (MAA: 51.5; FAA: 50.2; p > 0.05) (Tables 2 and 3).

There was no significant difference in the patients’ ability to return to the profession previously practised; in the male group, 36.4% returned successfully; in the female group, 30.8% (p > 0.05). Around a third of all patients went into regular retirement early. The remaining patients adapted their work to the remaining impairment.

In a free question about the expected gait pattern after ankle arthrodesis approximately 34% of women stated that the result was worse than expected (MAA: 16.1%). Again, significantly more men than women stated that the result was better than expected (MAA: 48.3%; FAA: 31.5%, p = 0.005). The same number of participants, regardless of sex, stated that the result was as expected (MAA: 35.7%; 34.3%; p > 0.05) (Fig. 2). Approximately a third of all patients were able to return to their previous profession regardless of sex. In turn, half of all patients had to reduce their working hours, adjust their workload, or retire early (p > 0.05).

Fig. 2 Relationship between preoperative expectations in men and women and the actual gait pattern after tibiotalar arthrodesis. Data in %, (p < 0.05)

In approximately 85% of cases (MAA: 84.6%; FAA: 86.3), three cannulated screws with a diameter of 6.5 mm were used (Figs. 3 and 4). The remaining cases were divided between arthrodeses using anterior placed locking plates and combined procedures. No influence on the clinical result was derived, which is why a separate presentation is not provided. Similarly, no influence could be attributed to the respective surgeon, the use of cancellous bone interposition, or simultaneous osteoarthritis of the distal tibiofibular joint.

Fig. 3 Postoperative radiographic findings of a 53-year-old men, treated with tibiotalar arthrodesis in 2-screw fixation technique. (a, b) Anteriorposterior and lateral view, 4 years post operation, left ankle

Fig. 4 Postoperative radiographic findings of a 58-year-old women, treated with tibiotalar arthrodesis in 3-screw fixation technique. (a, b) Anteriorposterior and lateral view, 3 years post operation, right ankle

Complications

The average complication rate for all patients was 7.3% (MAA: 6.3%; FAA: 8.9%) and consisted of delayed wound healing, delayed union, and soft tissue infections (Table 3). There was no significant difference between the groups. At the time of follow-up (mean 5.8 years), all arthrodeses were finally healed.

Discussion

Arthrodesis for terminal osteoarthritis of the ankle was confirmed to be a sufficient surgical procedure for men and women when previous non-surgical treatment had failed [11, 12]. The most important finding was that even though the mean values of all the scores surveyed are comparable with those in the current literature, there were significant differences in outcomes between men and women.

The demographic data such as age, BMI, and nicotine abuse were comparable between the sexes, as previously found with painful limitations up until the time of arthrodesis. A mean number of four previous operations was also equally distributed.

The revision rate was 2.3% (MAA: 3.5%; FAA: 0.0%) and, thus, was below the average of 5–11% in previous studies with both sexes [13–15]. If minor complications such as delayed wound healing and delayed union were included, the overall complication rate was 7.2%, which is still at the lower end of the range in the comparative literature at a sometimes worrying 26% [13, 16–19]. Since no permanent non-union was observed in the present study, the outcome can certainly be achieved using more modern procedures such as arthroscopically assisted arthrodesis, or the necessity of this can be critically questioned [20].

The question of whether arthrodesis or joint replacement is the preferred treatment for post-traumatic destruction of the tibiotalar joint is still an open one. Although no direct comparison can be made in the present study, the results of the patient reported outcome measures scores (PROMs) are in the upper range of satisfaction as reported after total ankle replacement [13, 15, 21]. Wasik et al., for example, reported an SF-12 score of 26.6 to 38.0 points for both arthrodesis and total ankle replacement [22]. The pain situation can also be compared with the previous literature with similar questions; for example, Dalat et al. showed patients with an FFI pain of 16.6 for total ankle replacement and 24.8 for ankle arthrodesis, regardless of sex [23].

A study by Eichler et al. found a higher OMAS with an average of 70 points, although only patients with haemophilic arthropathy were included [24]. Naturally, patients with post-traumatic osteoarthritis, as in the present study, have a comparatively poorer bone stock and often a significant axial deformity and pronounced soft tissue damage due to the previous trauma and or subsequent surgery.

The surgical procedure itself also corresponds to the currently recognised procedure for arthrodesis of the ankle joint. In the present study, more than 80% of the arthrodeses were performed using a three-screw fixation, placed convergently; the diameter was always 6.5 mm (Fig. 3). Regardless of biomechanical cadaver studies, no conclusive statement can yet be made about the superiority of 2 vs. 3 screw fixation, the exact placement thereof, or the necessity of locking fusion plates [25–27].

A remarkable result from our study was that the women had significantly worse values in all validated scores: FFI-D for pain and disability, OMAS, and SF-12 with physical component summary. The mental component summary of the SF-12 alone was also worse, but not significantly so. Possible explanations may be attributed to a naturally lower muscle mass. Men and women tend to have different levels of muscle mass. Pain, particularly of traumatic origin or due to orthopaedic problems, correlates positively with decreasing muscle mass and muscle activity and a lower muscle-fat ratio is associated with more pain [28–30]. The need to maintain a normal BMI is not affected by the previous consideration. Regenerative sport helps both sexes to maintain joint function or to cope with everyday tasks after arthrodesis. Furthermore, men may have a greater urge to exercise and, therefore, intrinsic motivation to exercise after arthrodesis. Another possible explanation could be that men generally tend to overestimate their state of health and underestimate their actual limitations [31, 32]; a phenomenon that seems to occur regardless of age [33].

Another influencing factor could be the choice of footwear. Men are generally used to wearing flat shoes both at work and at home. On the other hand, it is conceivable that women instead change their preferred footwear more frequently. Even if the subtalar joint continues to allow mild plantar flexion, rolling in the gait cycle after arthrodesis is primarily made possible by orthopaedically adapted footwear. This consideration is linked to the next most relevant influencing factor that was objectified in this study: expectations.

At 34%, significantly more women were not satisfied with the surgical result or stated that their gait pattern after arthrodesis was worse than expected; among men, the proportion was only 16%. Again, almost 50% of all men stated that their gait was significantly better than expected after the operation, compared with only 31% of women. In the case of arthrodeses such as those presented in this study, the expectation of the surgical result plays a significant role in the subsequent clinical outcome. Furthermore, women in particular can also have a poorer outcome after orthopaedic surgery [11, 34–36]. Licina and Johnston et al. were able to prove that satisfaction with the surgical outcome does not correlate with previous pain; however, realistic expectations do correlate with a good outcome [37–39]. In their study, Hueppe et al. concluded that women expected more intense postoperative discomfort during general surgery and also complained significantly more frequently about negative symptoms such as dizziness, nausea, and pain [40]. It is quite conceivable that such negative expectations could also explain the discrepancy in outcomes between men and women.

In addition to the strength of a numerically strong study with the inclusion of a homogeneous population, various limitations should be mentioned. Due to the nature of the retrospective study design, no case number calculation was performed, and the actual improvement in health status pre- and post-operatively cannot be sufficiently objectified. In line with the male-dominated clinical picture of post-traumatic osteoarthritis of the ankle, only a limited amount of data on sex-specific differences for the same question can be found in previous literature.

Conclusions

The fact that clinical outcomes can be significantly worse in women after ankle arthrodesis should be considered when determining the indication, and mentioned in the information discussion. However, the different expectations of men and women must also be considered by the surgeon and realistically adjusted by the patient.

Acknowledgements

Not applicable.

Author contributions

Methodology, Conceptualization, S.F. and O.N.; draft preparation writing original, and writing review and editing, S.F. and M.M.; validation, software, and formal analysis, E.H. and P.S.; data curation and investigation, O.N. and M.R.; supervision and resources, E.H. and M.R.; project administration, R.H. and S.F. All authors reviewed the manuscript and agreed to the publishing.

Funding

No additional external funding was provided for this research.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

All procedures were carried out in accordance with the 1964 Declaration of Helsinki. Subsequent amendments to the declaration were also acknowledged. The Ethics Committee thoroughly reviewed and approved this study prior to initiation (DRKS00034373, approved by 03 January 2023).

Consent for publication

Informed consent was obtained from all subjects involved in this study. Written informed consent has been obtained from the patients to publish this manuscript.

Competing interests

The authors declare no competing interests.

Abbreviations

BMI Body Mass Index

FAA Female Ankle Arhtodesis

FFI-D Foot Function Index in its validated German version

MAA Male Ankle Arthrodesis

OMAS Olerud Molander Ankle Score

PROMs Patient-Reported Outcome Measures

SEM Standard Error of the Mean

SF-12 Short-Form Health Survey

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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