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

Purpose

Tibiotalocalcaneal (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.

Methods

This 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.

Results

A 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 (p = 0.825). Postoperative VAS scores were significantly lower in the fibular excision group (p = 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 (p = 0.945). Operative time was significantly shorter in the fibular excision group (p < 0.001).

Conclusion

In 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.

Keywords

tibiotalocalcaneal arthrodesis fibula onlay graft intramedullary nail ankle arthritis post-traumatic arthritis arthrodesis outcomes

Introduction

Tibiotalar (TT) osteoarthritis (OA) is a degenerative condition that typically presents with pain and restricted ankle motion. In most cases, it develops after trauma, with ankle fractures being the leading cause.^1,2 As the disease progresses, it can significantly impair daily function and quality of life, sometimes to an extent comparable with other severe chronic conditions. Despite advances in implant technology, ankle arthrodesis remains the most reliable treatment option for end-stage ankle arthritis.³

Because the ankle and hindfoot function as a unit, pathology in one joint often affects adjacent joints. For this reason, tibiotalocalcaneal (TTC) arthrodesis is frequently preferred in patients with combined joint involvement, as it provides a stable, plantigrade, and pain-free foot.³ A variety of fixation techniques have been described for this procedure, including screws, plates, external fixation, and intramedullary nails (IMN).⁴

In clinical practice, surgeons often face patients who require TTC arthrodesis after previous ankle fracture fixation. In these cases, one practical question arises: should the fibula be excised, or should it be preserved and used as an onlay graft? The answer is not straightforward, especially when considering the potential effects of prior surgery on soft tissue and vascular integrity.

Retrograde intramedullary nailing has been used for ankle arthrodesis for decades and remains a widely accepted technique, particularly in post-traumatic cases involving both the ankle and subtalar joints.^5,6 To enhance fusion and reduce complications such as nonunion or infection, additional procedures—such as fibular excision or fixation of the fibula as an onlay graft—have been proposed.^7,8 However, the relative advantages of these approaches are still debated, and there is no clear consensus in the literature.^7–9

An important limitation of previous studies is that they often include heterogeneous patient populations and rarely focus on patients with prior lateral malleolar fixation. In this specific setting, the biological condition of the fibula may already be altered. Repeated surgical interventions—including initial fixation, implant removal, and subsequent osteotomies—can negatively affect vascularity and bone quality. As a result, the theoretical advantages of using the fibula as a graft may not be fully realized. Previous surgical fixation of the fibula may compromise its vascularity and biological potential. Plate-and-screw fixation has been shown to disrupt periosteal blood supply and cortical perfusion, particularly after hardware removal or repeated surgical exposure.¹⁰ In such cases, the fibula may function primarily as a structural graft with limited biological contribution.

In fibulae that have undergone plate-and-screw fixation, vascular compromise is a realistic concern. Additional surgical steps performed during TTC arthrodesis may further reduce biological viability. Under these conditions, the expected benefits of fibular grafting—such as improved union rates or faster healing—may be limited.^7–11

Based on this rationale, we hypothesized that in patients with prior lateral malleolar fixation, the fibula may have reduced biological potential and therefore may not provide a meaningful advantage when used as an onlay graft. We specifically hypothesized that fibular preservation would not provide superior postoperative pain relief, functional improvement, or union benefit compared with fibular excision in patients with prior lateral malleolar fixation.

Methods

This retrospective study was conducted following approval from the institutional ethics committee (approval no: KAEK/2025.10.263). All procedures were carried out in accordance with the Declaration of Helsinki.

Between February 2017 and March 2023, patients who had previously undergone plate-and-screw fixation of the lateral malleolus and subsequently required tibiotalocalcaneal (TTC) arthrodesis with a retrograde intramedullary nail for post-traumatic ankle osteoarthritis were reviewed.

Patient selection

Patients aged between 18 and 80 years with a history of closed bimalleolar or trimalleolar fractures treated with plate-and-screw fixation of the lateral malleolus were included. All patients had persistent pain and functional limitation despite conservative treatment.

Patients were excluded if they had ankle arthritis due to other causes (such as inflammatory disease, neuromuscular conditions, or congenital deformities), uncontrolled systemic conditions that could impair bone healing (e.g., uncontrolled diabetes, peripheral vascular disease), multiple previous ankle surgeries, open fractures, inadequate follow-up, or incomplete clinical or radiographic data.

Patients were divided into two groups according to the surgical technique used; Group 1 (fibular excision), Group 2 (fibula preserved and utilized as an onlay graft).

The choice of technique was based on the surgeon’s intraoperative preference. In general, fibular preservation was preferred when the fibula was deemed structurally intact and suitable for fixation, whereas fibular excision was performed in cases with poor bone quality, deformity, or when easier access to the ankle and subtalar joint was required. However, no strict predefined criteria were used, which may have introduced selection bias.

Surgical procedure

All procedures were performed by the same experienced orthopedic surgeon under tourniquet control and standard antibiotic prophylaxis (cefazolin).

Previous implants were removed through the original incision when possible or via an extended lateral approach when necessary. Joint surfaces were prepared by removing residual cartilage and osteophytes, followed by subchondral bone preparation and microfracture.

Alignment was achieved in neutral dorsiflexion, slight valgus (approximately 5°), and external rotation (5–10°), and confirmed using fluoroscopy (Figure 1).

Figure 1.

Postoperative plain radiographs of a 58-year-old woman who underwent tibiotalocalcaneal arthrodesis with fibular excision for post-traumatic arthritis after a trimalleolar fracture: (a) anteroposterior view; (b) lateral view.

In Group 1, the distal fibula was osteotomized and excised. Cancellous bone graft was harvested from the fibula and supplemented with iliac crest graft as needed (Figure 2).

Figure 2.

Postoperative plain radiographs of a 57-year-old woman who underwent tibiotalocalcaneal arthrodesis with the fibula fixed as an onlay graft for post-traumatic arthritis after a bimalleolar fracture: (a) anteroposterior view; (b) lateral view.

In Group 2, the fibula was preserved, mobilized via proximal osteotomy, and prepared for fixation. After nail insertion and graft placement, the fibula was decorticated and fixed to the tibia and talus using cannulated screws as an onlay graft.

A retrograde intramedullary nail (Tasarımmed, Turkey) was used in all cases and locked proximally and distally.

Postoperative management

All patients were immobilized in a short-leg splint postoperatively. Early toe mobilization was encouraged. Immobilization was discontinued at 6 weeks, followed by gradual weight bearing, with partial loading at 8 weeks and full weight bearing at approximately 12 weeks.

Outcome measures

Patients were followed at regular intervals, particularly during the first 6 months postoperatively, and then annually. The primary outcome of the study was postoperative pain measured by VAS at final follow-up. Secondary outcomes included postoperative AOFAS score, time to union, operative time, and postoperative complications.

Radiographic union was primarily assessed at routine follow-up visits using standard anteroposterior and lateral radiographs. Union was considered achieved at the first visit demonstrating bridging bone across at least three cortices, obliteration of the joint space, and trabecular continuity. Computed tomography (CT) was obtained only in cases where plain radiographs were inconclusive. The two observers assessed the images independently and were blinded to each other’s evaluations, although blinding to surgical technique was not possible because the fibular procedure could be recognized on imaging.

Union status was assessed independently by two orthopedic surgeons who were blinded to each other’s evaluations. Because the fibular procedure was identifiable on postoperative imaging, blinding to treatment group was not feasible. Interobserver agreement was evaluated using Cohen’s kappa coefficient.

Clinical outcomes were assessed using the Visual Analog Scale (VAS) for pain and the American Orthopaedic Foot and Ankle Society (AOFAS) score. These were recorded preoperatively and at final follow-up.

Operative time, time to union, and complications (including nonunion and wound problems) were also recorded.

Patients with nonunion were retained in analyses related to complications and union, but were excluded from functional outcome analyses because final postoperative AOFAS and VAS scores were not considered comparable to successfully fused cases.

Statistics

Statistical analyses were performed using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY, USA). The distribution of continuous variables was assessed using the Shapiro–Wilk test.

Continuous variables were expressed as mean ± standard deviation or median (range), depending on data distribution. Between-group comparisons were conducted using the independent-samples t-test for normally distributed data and the Mann–Whitney U test for non-normally distributed data. Categorical variables were compared using Fisher’s exact test. Within-group comparisons were performed using paired-samples t-tests.

Effect sizes were calculated to support the interpretation of findings and reported as Cohen’s d for parametric data or rank-biserial correlation for non-parametric data.

Interobserver agreement for the assessment of radiographic union was evaluated using Cohen’s kappa coefficient. The strength of agreement was interpreted according to Landis and Koch’s criteria: values <0.00 indicated poor, 0.00–0.20 slight, 0.21–0.40 fair, 0.41–0.60 moderate, 0.61–0.80 substantial, and 0.81–1.00 almost perfect agreement.¹²

A post-hoc power analysis was performed using G*Power software (version 3.1.9.7, Heinrich Heine University, Düsseldorf, Germany) based on the observed between-group difference in operative time, with an alpha level of 0.05. A post-hoc power analysis was performed for the operative time comparison only and should not be interpreted as evidence of adequate power for all study outcomes.

A p-value <0.05 was considered statistically significant.

Results

A total of 52 patients who underwent tibiotalocalcaneal arthrodesis between February 2017 and March 2023 were assessed for eligibility. Thirteen patients were excluded due to loss to follow-up (n = 7) or failure to meet the inclusion criteria (n = 6). The remaining 39 patients were allocated to Group 1 (n = 20) and Group 2 (n = 19). During follow-up, nonunion was observed in one patient in each group. These patients were excluded from analyses of functional outcomes but were retained for the assessment of complications. Consequently, 37 patients (Group 1: n = 19; Group 2: n = 18) were included in the final analysis. The flowchart of patient selection and study population is shown in Figure 3.

Figure 3.

Flowchart of patient selection and study population.

Final union status was determined by evaluating standard radiographs and CT scans sequentially. The inter-rater reliability for the final decision showed almost perfect agreement (κ = 0.85) (Table 1).

Table 1.

Inter-rater reliability of the final union decision between two observers.

Parameter	Cohen’s Kappa (κ)	95% CI	Agreement strength	p Value
Radiographic union	0.85	0.75–0.95	Almost perfect	<0.001

Interobserver agreement was assessed using Cohen’s kappa coefficient with 95% confidence intervals.

Bold values indicate statistically significant differences (p < 0.05).

When the two groups were compared, baseline clinical scores were largely similar. Preoperative AOFAS scores did not differ significantly between patients who underwent fibular onlay grafting and those who had fibular excision (p = 0.484). Likewise, preoperative pain levels, assessed using the VAS, were almost identical in both groups (p = 0.944). These findings indicate that the groups were comparable at baseline (Table 2).

Table 2.

Baseline demographic and clinical characteristics.

Characteristic	Group 1 (n = 19)	Group 2 (n = 18)	p Value
Sex (n)
Female	14	10	0.313
Male	5	8	0.313
Age (Year) mean (range)	59.8 (45–74)	55.6 (27–6)	0.295
BMI (kg/m²) mean (range)	27.5 (21.7–32.9)	27.2 (23.2–33.7)	0.749
Follow-up (months)	42.2 ± 14.7	45.5 ± 15.8	0.290
Preop AOFAS	34.8 ± 10.1	32.8 ± 8.0	0.484
Preop VAS	7.48 ± 0.87	7.40 ± 0.94	0.944

Continuous variables were compared using the independent samples t-test, and categorical variables were analyzed using Fisher’s exact test.

At final follow-up, both groups showed clear clinical improvement. Postoperative AOFAS scores increased substantially in both groups, reaching similar levels, and no meaningful difference was observed between the techniques (p = 0.825). In other words, both surgical approaches appeared to provide comparable functional outcomes (Table 3) (Figure 4).

Table 3.

Clinical and radiological outcomes.

Outcome	Group 1 (n = 19)	Group 2 (n = 18)	p-value	Effect size
Postop AOFAS	77.0 ± 3.0	77.2 ± 2.7	0.825
Postop VAS	1.00 ± 0.58	1.28 ± 0.67	0.011	0.45
Time to union (weeks)	15.21 ± 0.79	15.50 ± 1.86	0.945
Operative time (min)	128.68 ± 8.31	144.17 ± 7.79	<0.001	1.92
Follow-up (months)	42.2 ± 14.7	45.5 ± 15.8	0.290

Continuous variables were compared using the independent samples t-test, and effect sizes were calculated using Cohen’s d.

Figure 4.

Comparison of clinical outcomes between groups. (a) Postoperative AOFAS scores were similar between groups, with no significant difference observed (p = 0.825). (b) Postoperative VAS scores were significantly lower in the fibular excision group (p = 0.011), indicating improved pain outcomes.

Pain outcomes showed a slightly different pattern. Although both groups experienced a marked reduction in VAS scores after surgery, patients in the fibular excision group reported lower postoperative pain levels compared to those in the onlay graft group (p = 0.011) (Figure 4). The effect size for this difference was moderate (Cohen’s d = 0.45), indicating a clinically meaningful advantage in postoperative pain for the fibular excision group (Table 3).

Radiographic healing followed a similar pattern in both groups. The time to union was nearly identical (p = 0.945), indicating that preserving the fibula as an onlay graft did not accelerate bone healing in this cohort (Table 3).

A more pronounced difference emerged when operative time was considered. Procedures in the fibular excision group were completed in a significantly shorter time compared to those in the onlay graft group (p < 0.001) (Figure 5). The effect size for this difference was very large (Cohen’s d = 1.92), reflecting a substantial and clinically relevant reduction in surgical duration when the fibula was excised (Table 3). Based on the observed difference in operative time between groups, post-hoc power analysis demonstrated a statistical power exceeding 99% at an alpha level of 0.05.

Figure 5.

Comparison of operative time between groups. Procedures in the fibular excision group were significantly shorter than those in the fibular onlay graft group (p < 0.001), indicating a substantial reduction in surgical duration.

Follow-up duration was comparable between groups (p = 0.290).

Overall, both techniques yielded comparable functional and radiographic outcomes. However, fibular excision was associated with shorter operative time and improved postoperative pain outcomes.

Discussion

This study aimed to address a practical question frequently encountered in clinical practice: in patients with prior lateral malleolar fixation, does preserving the fibula as an onlay graft provide any additional benefit during TTC arthrodesis? Based on our findings, the answer appears to be no. TTC arthrodesis with a retrograde intramedullary nail resulted in high union rates and satisfactory functional outcomes. However, fibular preservation did not improve union time or functional scores. Instead, it was associated with longer operative time and higher postoperative pain scores. This finding was further supported by a moderate effect size (Cohen’s d = 0.45), indicating that the reduction in postoperative pain observed in the fibular excision group is not only statistically significant but also clinically meaningful. The higher postoperative pain observed in the fibular onlay graft group may be multifactorial in origin. Soft tissue irritation, periosteal stripping, and mechanical irritation from fixation materials may contribute to persistent postoperative discomfort. Furthermore, the fibula itself may act as a stress-transmitting structure after fixation, potentially influencing local pain perception.

Intramedullary nailing has long been recognized as a reliable method for ankle and hindfoot arthrodesis. Biomechanical studies have consistently demonstrated its advantages in terms of rotational stability, bending stiffness, and compression across the fusion site.^13–15 It is important to distinguish between different arthrodesis constructs. In tibiotalocalcaneal arthrodesis using a retrograde intramedullary nail, the construct itself provides substantial intrinsic stability, which may reduce the need for additional biological or mechanical augmentation such as fibular onlay grafting. In contrast, in isolated tibiotalar arthrodesis, particularly when using less rigid fixation methods, fibular grafting may provide additional stability and has been associated with improved outcomes in some studies. This distinction may explain why, in our cohort, additional fibular onlay grafting did not translate into improved union or functional outcomes. We observed a high union rate (94.9%) and functional outcomes comparable to those reported in the literature.^3,16–20 It is worth noting that our study population consisted exclusively of patients with post-traumatic arthritis. By excluding conditions such as Charcot neuropathy and inflammatory disease, we likely minimized biological variability and created a more favorable environment for fusion. This may explain why our outcomes are at least comparable, if not slightly better, than those reported in more heterogeneous cohorts.^7,10,20,21

The role of the fibula in ankle and TTC arthrodesis remains controversial. Several authors have proposed that using the fibula as an onlay graft may enhance fusion by providing both biological support and additional mechanical stability.^3,7,20,22 In theory, a well-vascularized fibula with preserved periosteum could accelerate bone healing. However, clinical evidence has not consistently confirmed this advantage, and no clear consensus has been established regarding its routine use.^{3,7,8,17–20,22,23} In daily practice, comparable outcomes are often achieved with different techniques, suggesting that the benefit of fibular grafting may be more context-dependent than previously assumed.

Our results support this view, but also highlight an important detail: the biological condition of the fibula. In patients with prior plate-and-screw fixation, the fibula has already been subjected to surgical trauma. Implant removal and additional osteotomies performed during TTC arthrodesis may further compromise vascularity and structural integrity. Under these circumstances, the fibula may not retain sufficient biological capacity to function effectively as a graft.

The difference in operative time between the groups is particularly notable. This difference was associated with a very large effect size (Cohen’s d = 1.92), indicating a substantial and clinically meaningful reduction in operative time. Procedures involving fibular fixation were significantly longer, which is not surprising given the additional steps required for graft preparation and fixation. In a region already vulnerable to soft-tissue complications, prolonged operative time may not be trivial. Although our study was not specifically powered to analyze complications, the higher rate of wound problems observed in the fibular fixation group follows the same pattern. This finding is consistent with previous reports suggesting that fibular onlay grafting may increase operative time and complication risk due to additional surgical manipulation and hardware use.^8,23

From a biological standpoint, the limitations of non-vascularized fibular grafts should also be considered. These grafts primarily offer osteoconductive support, while their osteoinductive and osteogenic potential is limited. Early resorption has been reported, and in certain settings, failure rates can be considerable.²⁴ For this reason, augmentation with cancellous grafts is often recommended, particularly when vascularity or bone quality is compromised.²⁵ In our cohort, the distal fibula had already undergone previous surgical intervention, and its biological capacity was likely further reduced during revision procedures. This may help explain why preserving the fibula did not translate into improved union outcomes.

Another point that deserves attention is the preoperative evaluation of the fibula. Most studies examining fibular onlay grafting do not take into account whether the fibula has been previously operated on. However, as highlighted by Kumar et al., factors such as prior surgery, poor bone stock, and compromised soft tissue can significantly influence both union and functional outcomes.¹¹ Our findings reinforce this perspective and suggest that fibular viability should be assessed individually rather than assumed to be adequate in all cases.

When complication rates are considered, our results fall within the range reported in the literature. However, the higher rate of wound-related complications in the fibular fixation group is noteworthy. Although the difference did not reach statistical significance, likely due to the limited number of events, the trend supports the idea that more complex surgical procedures may carry additional risk, particularly in previously operated tissues. Similar observations have been reported by Bernasconi et al. and Jehan et al., who emphasized the impact of surgical complexity and patient-related factors on complication rates.^8,26

Demographically, our cohort was comparable to those reported in previous studies, and the similarity between groups represents a methodological strength. This homogeneity reduces the likelihood that baseline differences influenced the observed outcomes. At the same time, several limitations should be acknowledged. The retrospective design and relatively small sample size limit the strength of our conclusions. Given the limited number of events, this analysis should be interpreted cautiously. In particular, the low number of complications limits the statistical strength of complication-related analyses, and these findings should therefore be interpreted with caution. Larger, prospective studies are needed to validate these results. Although the surgical decision was based on intraoperative judgment, baseline comparability between groups suggests that this bias may have had a limited influence on the primary outcomes. Another limitation is the use of the AOFAS score, which combines clinician-based and patient-reported components and has known limitations in terms of validity and responsiveness compared with modern patient-reported outcome measures.

Finally, the extent to which fibular vascularity is affected by repeated surgical interventions remains unclear. While our study provides indirect clinical evidence, this issue can only be fully clarified through studies specifically designed to assess bone perfusion using objective methods, such as dynamic or in vivo imaging techniques.

Conclusion

Overall, our findings indicate that routine use of the fibula as an onlay graft during TTC arthrodesis may not be necessary in patients with prior lateral malleolar fixation. Although retrograde intramedullary nailing provides reliable union and satisfactory functional outcomes, preserving the fibula did not offer additional clinical or radiological benefit in this specific setting. Instead, it was associated with increased operative time and higher postoperative pain levels. These results support a more selective approach, in which the decision to preserve the fibula should be guided by its biological condition rather than applied routinely.

Footnotes

ORCID iDs

Adem Sahin

Ali Ozyalcin

Anil Agar

Fatih Şentürk

Soner Kocak

Cemil Erturk

Ethical considerations

This study was approved by the institutional ethics committee (approval no: KAEK/2025.10.263). All procedures were performed in accordance with the Declaration of Helsinki. Written informed consent for treatment and use of anonymized data had been obtained according to institutional policy.

Consent to participate

The requirement for informed consent was waived due to theretrospective design.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respectto the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.*

Location of work

The investigation was performed at Istanbul University Of Health Sciences Kanuni Sultan Suleyman Training And Research Hospital, Istanbul, Turkey.

Appendix

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