Tibial Component Malalignment in Total Ankle Arthroplasty

Background: Total ankle replacement (TAR) has emerged as a valuable alternative to ankle arthrodesis for the treatment of end-stage ankle osteoarthritis, offering pain relief while preserving joint motion and improving quality of life. Despite advances in implant design and surgical techniques, complications remain common, and tibial component malalignment has been increasingly recognized as a major contributor to implant failure and revision surgery. Purpose: To provide a comprehensive overview of the current evidence regarding tibial component malalignment in TAR, focusing on its etiology, radiographic assessment, biomechanical implications, clinical consequences, and available treatment strategies. Methods: A narrative review of the literature was conducted using PubMed, Scopus, and Web of Science. English-language studies published up to 2026 investigating tibial component positioning, malalignment, associated complications, and revision strategies in TAR were included and qualitatively analyzed. Results: Tibial component malalignment is a multifactorial condition influenced by preoperative deformities, patient-specific anatomy, surgical technique, instrumentation, and surgeon experience. Malposition in the coronal, sagittal, or axial planes alters ankle biomechanics, resulting in abnormal load distribution, altered kinematics, polyethylene wear, instability, and increased stress at the bone-implant interface. These changes may lead to pain, aseptic loosening, subsidence, osteolysis, and ultimately prosthetic failure. Weight-bearing radiographs remain the standard imaging modality for postoperative assessment, while weight-bearing computed tomography provides complementary three-dimensional evaluation, particularly in complex cases. Management should be individualized according to implant stability, degree of deformity, and symptom severity, ranging from supramalleolar osteotomy and isolated polyethylene insert exchange to partial or complete revision arthroplasty, including the use of custom implants in cases of substantial bone loss. Conclusions: Tibial component malalignment represents a critical determinant of functional outcomes and implant survivorship following TAR. Early recognition through standardized imaging and a thorough understanding of its biomechanical and clinical implications are essential to optimize treatment strategies, minimize revision rates, and improve long-term outcomes after total ankle replacement.