Patient-Specific vs Standard Instrumentation in Total Ankle Arthroplasty: A Systematic Review and Meta-analysis of Short-term Outcomes

Abstract

Background:

Patient-specific instrumentation (PSI) has been proposed to improve accuracy and efficiency in total ankle arthroplasty (TAA). Although cadaveric studies suggest improved precision, the clinical value of PSI over standard instrumentation (SI) remains uncertain.

Methods:

A systematic review and meta-analysis following PRISMA guidelines was performed using PubMed, Embase, and Cochrane databases through July 2025. Comparative studies evaluating PSI vs SI in TAA were included. Outcomes analyzed included patient-reported outcome measures (PROMs), radiologic alignment, intraoperative efficiency, complication and revision rates, and cost. Random effects models were used to pool standardized or mean differences (MDs) or risk ratios with 95% CIs.

Results:

Eleven studies comprising 802 implants (438 PSI, 364 SI) were included, with follow-up ranging from 3 months to 2 years, representing short-term outcomes. No statistically significant differences were detected between PSI and SI in postoperative American Orthopaedic Foot & Ankle Society score or Ankle Osteoarthritis Scale scores, or in pooled functional improvements. Radiographic analysis showed no difference in coronal alignment, whereas PSI demonstrated slightly greater deviation from intended sagittal alignment compared with SI (MD 0.37 degrees, 95% CI 0.03-0.70; P = .03). Across studies using PSI, preoperative planning showed high agreement between planned and implanted tibial component size (92%), but lower agreement for talar sizing (69%). Operative and tourniquet times were comparable between groups; however, PSI significantly reduced fluoroscopy time (MD −38.35 seconds, 95% CI −59.33 to −17.36; P < .001). No statistically significant differences were detected in complication and revision rates. Cost analysis produced conflicting results, with one study suggesting potential savings and another finding PSI more expensive after accounting for preoperative imaging.

Conclusion:

PSI in TAA reduces fluoroscopy time but does not appear to enhance functional outcomes, complication rates, or revision risk compared with SI in the short term. PSI may result in greater deviation from sagittal alignment, and its cost-effectiveness remains uncertain. High-quality prospective studies with long-term follow-up are needed to clarify its role in routine and complex cases.