Fibular onlay grafting does not improve clinical or radiological outcomes but increases operative time in tibiotalocalcaneal arthrodesis after prior lateral malleolar fixation: A retrospective comparative study.

Abstract

PurposeTibiotalocalcaneal (TTC) arthrodesis is a well-established treatment for end-stage ankle arthritis. In patients with prior lateral malleolar fixation, the role of the fibula during arthrodesis remains controversial. While some surgeons prefer fibular preservation as an onlay graft, concerns exist regarding its biological viability after previous surgical interventions. This study aimed to compare clinical and radiological outcomes of fibular excision versus fibular onlay grafting in this specific patient population.MethodsThis retrospective comparative study included patients who underwent TTC arthrodesis using retrograde intramedullary nailing following prior plate-and-screw fixation of the lateral malleolus. Patients were divided into two groups based on surgical technique: fibular excision and fibular preservation as an onlay graft. Clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and Visual Analog Scale (VAS) for pain. Radiological evaluation included time to union. The primary outcome was postoperative pain assessed using the Visual Analog Scale (VAS), while secondary outcomes included AOFAS score, time to union, operative time, and complications.ResultsA total of 37 patients were included in the final analysis. Baseline characteristics were comparable between the groups. Both techniques resulted in significant improvement in AOFAS scores, with no significant difference between groups (<i>p</i> = 0.825). Postoperative VAS scores were significantly lower in the fibular excision group (<i>p</i> = 0.011), and this difference was supported by a moderate effect size (Cohen's d = 0.45), indicating clinical relevance. Time to union was similar between groups (<i>p</i> = 0.945). Operative time was significantly shorter in the fibular excision group (<i>p</i> < 0.001).ConclusionIn patients with prior lateral malleolar fixation, preserving the fibula as an onlay graft during TTC arthrodesis does not improve union or functional outcomes. Instead, fibular excision is associated with shorter operative time and lower postoperative pain.