Learning curve assessment for total ankle replacement using the transfibular approach

Camilla Maccario, Eric W. Tan, Claudia Angela Di Silvestri, Cristian Indino, H. Paco Kang, Federico Giuseppe Usuelli

Research output: Contribution to journalArticlepeer-review


Background: Total ankle arthroplasty is an increasingly effective option for the treatment of end-stage arthritis. One recent innovation utilizes a transfibular, lateral approach. Like any new system, there is likely a learning curve associated with its use. We analyzed a series of patients who received a total ankle arthroplasty via a transfibular approach to state if it is possible to identify and to evaluate effects of a learning curve in the use of this novel total ankle replacement system. Methods: 76 consecutive patients meeting inclusion and exclusion criteria were retrospectively analyzed. All patients had a minimum of 24 months of follow-up. Intraoperative parameters, preoperative and postoperative subjective outcome scores, radiographic parameters, and complications were recorded and evaluated. Results: There were significant learning curve effects on various surgical and postoperative parameters. Surgical time decreased with the curve stabilizing after the 16th patient. With regard to patient outcomes, a learning curve was identified for the VAS, AOFAS, and SF-12 MCS scores. The number of patients required to stabilize these curves were 21, 13, and 16, respectively. Alignment as measured by alpha and gamma angles also improved with experience, with the curves stabilizing at 18 and 15 patients, respectively. There was a larger number cases required for complication rates, with the curve stabilizing after the 39th patient. No significant learning curve was found for ankle ROM, SF-12 PCS, beta angle, tibio-talar ratio (TTR), or tibio-talar surface angle (TTS). Conclusions: This study demonstrates a significant learning curve with respect to operative time, patient outcomes, and radiographic parameters. Extrapolating this information, we urge surgeons to adequately familiarize themselves with any new implant through a training program in a high-volume center. Level of evidence: IV, case series.

Original languageEnglish
Pages (from-to)129-137
Number of pages9
JournalFoot and Ankle Surgery
Issue number2
Publication statusPublished - 2021


  • Ankle arthritis
  • Fix-bearing
  • Learning curve
  • Total ankle replacement
  • Transfibular approach

ASJC Scopus subject areas

  • Orthopedics and Sports Medicine


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