Is ankle replacement so primitive compared with other joint arthroplasties that we look at cement block “arthroplasty” as a success? Of course not, but a casual read of the title of this article might lead an orthopaedist to wonder. Cement block arthroplasty seems like a procedure right out of an orthopaedic text from the 1970s, so why should this be an article in JBJS in 2014?

A closer inspection of the study by Lee et al. shows that it is really a collection of three different, rarely indicated procedures:

1. Talar body replacement for patients with a tumor without destruction of the ankle and subtalar joints. Several case reports have shown some success with use of custom talar body implants, with the native talar neck and head left intact or the entire talus replaced with metal or ceramic．

2. Ankle/hindfoot arthrodesis with tibiotalocalcaneal screws and cement for structural support, with the intention of achieving a stable pseudarthrosis.

3. Cement block arthroplasty, in which the cement is a rigid spacer, with emphasis on restoration of alignment.

The first procedure, talar body replacement, is a unique operation for a younger patient with a tumor. However, the second and third procedures are for patients with loss of the ankle joint and extensive destruction of the talus, possibly with infection. In most cases, this loss and destruction are the result of trauma (talar fracture complications) or a failed total ankle replacement. (Patients with neuropathic arthropathy, or a Charcot ankle, may also have erosive arthritis of the ankle and hindfoot, but salvage with a tibiocalcaneal fusion may be easier because a stable nonunion is usually good enough. This disease entity differs from a failed total ankle replacement and thus should be considered separately.)

Options are limited for treating a patient with extensive destruction of the ankle and talus (without neuropathy). A true tibiotalocalcaneal fusion requires structural bone graft and has a longer healing time, a higher nonunion rate, and inferior outcomes compared with routine ankle fusion. Resection of the talar body (talectomy), possibly with a Blair fusion (fusion of the talar neck to the distal part of the tibia), is another option but is similar to tibiotalocalcaneal fusion, with lots of stiffness and mediocre results. Transtibial (below-the-knee) amputation is another possibility and may offer better outcomes in younger patients, but with obvious long-term financial, emotional, and psychological costs.