Different complication patterns between anterior and lateral approaches in total ankle arthroplasty: A systematic review and meta‐analysis

Purpose The optimal surgical approach for total ankle arthroplasty (TAA) remains debated. The anterior and lateral transfibular approaches differ in surgical exposure and may influence complication patterns. This systematic review and meta‐analysis aimed to compare revision rates, overall complication rates and specific complication profiles between anterior and lateral approaches in TAA. Methods A PRISMA‐compliant systematic review of PubMed, Embase and Scopus databases was performed. Studies reporting complications following primary TAA performed through either approach were included if they met predefined methodological quality criteria (QualSyst score ≥ 75%). Complication rates were compared using Fisher's exact test, and correlations between complication rates and patient or surgical factors were explored. Results Fifty‐one studies were included, comprising 7959 TAA procedures (7225 anterior and 734 lateral). Revision rates were higher in the anterior approach group (7.5% vs. 1.9%, p < 0.001), as were rates of malleolar fractures (1.7% vs. 0.3%, p = 0.001) and aseptic loosening (2.8% vs. 0.14%, p < 0.001). Deep infections were reported more frequently in lateral approach cohorts (3.1% vs. 0.57%, p < 0.001), although this finding was influenced by outlier studies. Wound complications and polyethylene‐related complications were comparable between approaches. No association was observed between complication rates and patient age, body mass index or surgical time. Conclusion Anterior and lateral approaches in TAA appear to be associated with different complication patterns rather than clear differences in overall safety. Both approaches remain valid surgical options, but awareness of their distinct complication profiles may help guide intraoperative precautions and post‐operative surveillance. However, heterogeneity in implant design, follow‐up duration and study methodology limits definitive conclusions regarding the superiority of one approach. Level of Evidence Level I, systematic review/meta‐analysis.