Risk of Total Ankle Arthroplasty or Ankle Fusion Following Distal Tibial Fractures: A Systematic Review and Meta-Analysis

<b>Background</b>: Distal tibial fractures (DTFs) are a major cause of post-traumatic osteoarthritis (PTOA). The risk of conversion to total ankle arthroplasty (TAA) or ankle fusion (AF) after DTFs remains unclear, and the current literature provides heterogeneous and often incomplete data. The aim of this systematic review was to evaluate the incidence of TAA and AF following DTF-related PTOA and to explore potential predictors of conversion, including initial treatment strategy. <b>Methods</b>: A systematic review was conducted according to PRISMA guidelines. The PICO framework was applied during the study design and literature search phase to define the research question and eligibility criteria. Studies reporting adult patients with a history of DTFs who later developed PTOA and underwent TAA or AF were included. Descriptive statistics were performed. Study-level proportions of conversion to TAA, AF, or both were analyzed using random-effects meta-analysis with logit transformation. <b>Results</b>: Eight studies comprising 190,383 fractures met the inclusion criteria. Overall, 31,269 patients underwent TAA or AF, corresponding to a conversion rate of 16.4%. The pooled conversion incidence from the random-effects model was 5.6%, with considerable heterogeneity (I² ≈ 100%). When procedures were analyzed separately, the pooled incidence was 0.25% for TAA and 0.76% for AF. <b>Conclusions</b>: The risk of conversion to TAA or AF after DTFs appears to be relatively low, despite the high prevalence of PTOA. The higher conversion rate observed in surgically treated fractures likely reflects the complexity of the initial fracture rather than the failure of surgical management itself. Level IV, systematic review of retrospective studies.