Total Ankle Arthroplasty: A Comparative Review of Surgical Approaches and Outcomes.

» Total ankle arthroplasty (TAA) has evolved from an implant-limited procedure to a technique-sensitive operation, with surgical approach selection emerging as a key determinant of soft-tissue complications, deformity correction, and alignment accuracy. » Anterior and lateral transfibular approaches offer distinct advantages and tradeoffs in visualization, angiosome preservation, deformity correction, and technical complexity, and should not be viewed as interchangeable corridors. » Anterior approaches remain the most widely used and compatible with most implant systems but carry the highest risk of wound complications, particularly in patients with compromised anterior soft tissues or vascular disease. » The lateral transfibular approach provides extensile exposure and facilitates coronal-plane deformity correction while preserving anterior skin perfusion, at the cost of added bony morbidity, increased technical demands related to fibular osteotomy and fixation, and constrained revision options because failed lateral systems often require revision through an anterior approach using alternative implants. » Optimal outcomes in TAA depend less on the chosen approach itself than on appropriate patient selection, meticulous soft-tissue management, implant-approach compatibility, and surgeon experience, emphasizing the need for individualized, strategy-driven approach selection.