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Third-generation total ankle replacement (TAR) is an increasingly popular and effective treatment for end-stage osteoarthritis, yet identifying causes of failure remains challenging. We evaluated integrated bone SPECT/CT in recurrent pain after TAR by validating a standardized reporting scheme, identifying uptake patterns, and assessing diagnostic performance and impact on clinical management. A total of 24 TARs in 16 patients with persistent or recurrent pain received integrated bone SPECT/CT using diagnostic CT settings. Imag