• The 3D anatomical complexity of the foot and ankle and the importance of weight-bearing in diagnosis have required the combination of conventional radiographs and medical CT.

• Conventional plain radiographs (XR) have demonstrated substantial limitations such as perspective, rotational and fan distortion, as well as poor reproducibility of radiographic installations. Conventional CT produces high levels of radiation exposure and does not offer weight-bearing capabilities.

• The literature investigating biometrics based on 2D XR has inherent limitations due to the technology itself and thereby can focus only on whether measurements are reproducible, when the real question is whether the radiographs are.

• Low dose weight-bearing cone beam CT (WBCT) combines 3D and weight-bearing as well as ‘built in’ reliability validated through industry-standardized processes during production and clinical use (quality assurance testing).

• Research is accumulating to validate measurements based on traditional 2D techniques, and new 3D biometrics are being described and tested.

• Time- and cost-efficient use in medical imaging will require the use of automatic measurements. Merging WBCT and clinical data will offer new perspectives in terms of research with the help of modern data analysis techniques.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170066

• Ankle osteoarthritis (OA) is much less frequent than knee or hip OA, but it can be equally disabling, greatly affecting the quality of life of the patients.

• Approximately 80% of ankle OA is post-traumatic, mainly secondary to malleolar fractures, being another of the main causes untreated in chronic instability. The average age of the patient affected by ankle OA is around 50 years, being therefore active patients and in working age who seek to maintain mobility and remain active.

• The authors conducted a comprehensive review of the conservative, medical, and surgical treatment of ankle OA.

• Initial conservative treatment is effective and should be attempted in any stage of OA. From a pharmacological point of view, non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular infiltrations can produce temporary relief of symptoms.

• After the failure of conservative-medical treatment, two large groups of surgical treatment have been described: joint-preserving and joint-sacrificing procedures.

• In the early stages, only periarticular osteotomies have enough evidence to recommend in ankle OA with malalignment. Both ankle arthrodesis and ankle replacement can produce satisfactory functional results if correctly indicated in the final stages of the disease.

• Finally, the authors propose a global treatment algorithm that can aid in the decision-making process.