Outcome after total ankle replacement or ankle arthrodesis in end-stage ankle osteoarthritis on the basis of german-wide data: a retrospective comparative study over 10 years.

BACKGROUND: In symptomatic end-stage osteoarthritis of the ankle joint, total ankle replacement and ankle arthrodesis are the two primary surgical options for patients for whom conservative treatment fails. Published revision rates are often biased and difficult to compare. In this study, unplanned reoperation rates and revision rates were determined for both surgical interventions based on a large dataset, and risk factors for unplanned reoperations were identified. METHODS: German-wide health data of the largest German health-care insurance carrier between 2001 and 2012 were retrospectively analyzed, and unplanned reoperation rates within 10 years were determined for index surgeries conducted in 2001 and 2002. Unplanned reoperation rates within 5 years for index surgeries conducted in 2001/2002 were compared to index surgeries conducted in 2006/2007. Multivariate logistic regression was used to identify risk factors for unplanned reoperations. RESULTS: After ankle arthrodesis, 19% (95% confidence interval [CI], 16-22%) of 741 patients needed to undergo an unplanned reoperation within ten years. After total ankle replacement, the unplanned reoperation rate was 38% [95% CI, 29-48%] among 172 patients. For initial surgeries conducted at a later date, unplanned reoperation rates within five years were 21% [95% CI, 19-24%] for 1,168 ankle arthrodesis patients and 23% [95% CI, 19-28%] for 561 total ankle replacement patients. Significant risk factors for unplanned reoperations after ankle arthrodesis in the initial cohort were age < 50 years (odds ratio [OR] = 4.65 [95% CI 1.10;19.56]) and osteoporosis (OR = 3.72 [95% CI, 1.06;13.11]); after total ankle replacement, they were osteoporosis (OR = 2.96 [95% CI, 1.65;5.31]), Patient Clinical Complexity Level (PCCL) grade 3 (OR = 2.19 [95% CI, 1.19;4.03]), PCCL grade 4 (OR = 2.51 [95% CI, 1.22;5.17]) and diabetes mellitus (OR = 2.48 [95% CI, 1.33;4.66]). Kaplan-Meier analyses including 1,525 ankle arthrodesis patients and 644 total ankle replacement patients revealed an average unplanned reoperation-free time of approximately 17 years for both procedures. CONCLUSIONS: Similar revision rates and unplanned reoperation rates for both procedures in the later-date cohort can likely be attributed to a learning curve for surgeons as well as advances in implant design. This analysis of billing health insurance data supports an increase in total ankle replacement surgeries.

Trends in the use of ankle arthrodesis and total ankle replacements in Australia over the past 20 years.

BACKGROUND: End stage ankle osteoarthritis (OA) is debilitating. Surgical management consists of either ankle arthrodesis (AA) or a total ankle replacement (TAR). The purpose of this study is to assess the trends in operative intervention for end stage ankle OA in an Australian population. METHODS: This is a retrospective epidemiological study of 15,046 surgeries. Data were collected from publicly available national registries including the Australian Medicare Database and Australian Orthopaedic Association National Joint Replacement Registrar from 2001 to 2020. RESULTS: There was a significant increase in all ankle surgeries performed across the period of interest. AA remained the more commonly performed procedure throughout the course of the study (11,946 cases, 79.4%) and was never surpassed by TAR (3100, 20.6%). The overall proportions demonstrated no significant changes from 2001 to 2020. CONCLUSION: The incidence of ankle surgeries continues to increase with the ageing and increasingly comorbid population of Australia. Despite demonstrating no significant overall change in the ratio of TAR and AA in our study population and period, there are noticeable trends within the timeframe, with a recent surge favouring TAR in the last 5 years.

Analysis of early failure rate and its risk factor with 2157 total ankle replacements.

The failure rate of TAA is still higher than that of other joint replacement procedures. This study aimed to calculate the early failure rate and identify associated patient factors. Data from the Korean Health Insurance Review and Assessment Service database from 2009 to 2017 were collected. We evaluated patients who had TAA as a primary surgical procedure. Early failure was defined as conversion to revision TAA or arthrodesis after primary TAA within five years. Patients with early failure after primary TAA were designated as the "Failure group". Patients without early failure and who were followed up unremarkably for at least five years after primary TAA were designated as the "No failure group". Overall, 2157 TAA participants were included. During the study period, 197 patients developed failure within five years postoperatively, for an overall failure rate of 9.1%. Significant risk factors for early failure were history of chronic pulmonary disease, diabetes, peripheral vascular disease, hyperlipidemia, dementia, and alcohol abuse. A significant increase of odds ratio was found in patients with a history of dementia, chronic pulmonary disease, and diabetes. Surgical indications and preoperative patient counseling should consider these factors.

The Epidemiology and Trends of Primary Total Ankle Arthroplasty and Revision Procedure in Korea between 2007 and 2017.

BACKGROUND: The aim of this study was to investigate the surgical trends of primary total ankle arthroplasty (TAA) and revision procedure in Korea from 2007 to 2017 using national population-based data. METHODS: We reviewed the National Health Insurance data of Korea from 2007 to 2017. The data included diagnosis codes, procedure codes, prescriptions, medical costs, and other demographic data. Trends of primary diagnosis for primary TAA were evaluated. Annual trends and incidences per 100,000 person-years of primary TAA and revision procedures as well as compound annual growth rate (CAGR) during the study period were analysed. Surgical trends according to patients' age, hospital grades, and insurance systems were also evaluated. RESULTS: Primary diagnosis for primary TAA was mostly degenerative arthritis (6,501 cases; 90.5%). From 2007 to 2017, the total number of cases of primary TAA and revision procedures was 7,183 and 585, respectively. The number of cases in 2007 of primary TAA was 313; there were no cases of revision. The number of cases in 2017 of primary TAA were 986 and of revision were 108. The CAGR during this period was 28.6% for primary TAA and 44.6% for revision procedures. Incidences per 100,000 person-years in 2017 were 1.91 for primary TAA and 0.21 for revision procedures. The average cost paid by patients themselves was USD 813 (19%) and by the National Health Insurance Service was USD 3,480 (81%). CONCLUSION: The incidence of primary TAA and revision procedures steadily increases in Korea during the 11-year study period.

Total ankle replacement : comparison of the outcomes of STAR and Mobility.

Total Ankle Replacement is a recognised treatment for end-stage ankle arthritis and an alternative to arthrodesis. This study reviews a single centre series of prospectively collected outcome measures to determine whether the Mobility performs better than the Scandinavian ankle replacement. The primary outcome measure was the survivorship. Secondary outcome measures consisted of complications and international scoring systems. 147 Scandinavian and 162 Mobility ankle replacements were reviewed at a mean follow up of 12.4 and 7.7 years respectively. The revision rate, which included liner exchange, component exchange or removal of implant was at 7 years 12.3% (18) for Scandinavian and 5.2% (8) for Mobility. The complication rate was 16.5% (22) for Scandinavian compared to 9.9 % (15) for Mobility. The results of our unit compare favourably with previous published studies. In this study the Mobility has been shown to have more favourable results at 7 years compared to the Scandinavian.

12-year survival analysis of 322 Hintegra total ankle arthroplasties from an independent center.

Background and purpose - Total ankle arthroplasties (TAAs) have larger revision rates than hip and knee implants. We examined the survival rates of our primary TAAs, and what different factors, including the cause of arthritis, affect the success and/or revision rate.Patients and methods - From 2004 to 2016, 322 primary Hintegra TAAs were implanted: the 2nd generation implant from 2004 until mid-2007 and the 3rd generation from late 2007 to 2016. A Cox proportional hazards model evaluated sex, age, primary diagnosis, and implant generation, pre- and postoperative angles and implant position as risk factors for revision.Results - 60 implants (19%) were revised, the majority (n = 34) due to loosening. The 5-year survival rate (95% CI) was 75% (69-82) and the 10-year survival rate was 68% (60-77). There was a reduced risk of revision, per degree of increased postoperative medial distal tibial angle at 0.84 (0.72-0.98) and preoperative talus angle at 0.95 (0.90-1.00), indicating that varus ankles may have a larger revision rate. Generation of implant, sex, primary diagnosis, and most pre- and postoperative radiological angles did not statistically affect revision risk.Interpretation - Our revision rates are slightly above registry rates and well above those of the developer. Most were revised due to loosening; no difference was demonstrated with the 2 generations of implant used. Learning curve and a low threshold for revision could explain the high revision rate.

Total Ankle Arthroplasty and Ankle Arthrodesis Use: An American Board of Orthopaedic Surgery Part II Database Study.

Total ankle arthroplasty (TAA) use has increased during the past 20 years, whereas ankle arthrodesis (AAD) use has remained constant. The purpose of this study was to examine trends in TAA and AAD use in American Board of Orthopedic Surgery Part II candidates while considering the influence of fellowship training status on treatment of end-stage ankle arthritis. The American Board of Orthopedic Surgery Part II database was queried to identify all candidates who performed ≥1 TAA or AAD from examination years 2009 through 2018. Candidates were categorized by examination year and by self-reported fellowship training status. Descriptive statistical methods were used to report procedure volumes. Trends in use of TAA and AAD were examined by using log-modified regression analyses. From 2009through 2018, there was no significant change in TAA or AAD use among all candidates (p = .92, p = .20). Candidates reporting a foot and ankle fellowship trended toward increased use of TAA relative to AAD compared with non-foot and ankle fellowship candidates, but this failed to reach statistical significance (p = .06). The use of arthroscopic AAD increased over time (p < .01) among all candidates. TAA and AAD use did not change over the study period. Volume of TAA and AAD performed by early-career surgeons remains low. The findings in this study should serve as an important reference for orthopedic trainees, early-career surgeons, and orthopedic educators interested in optimizing training curriculum for surgical management of end-stage ankle arthritis.

Age, race, comorbidity, and insurance payer type are associated with outcomes after total ankle arthroplasty.

OBJECTIVE: To assess whether age, race/ethnicity, comorbidity, and insurance payer status are associated with outcomes after total ankle arthroplasty (TAA). METHODS: Using the US National Inpatient Sample (NIS) data and multivariable-adjusted logistic regression, we assessed the association of age, race/ethnicity, comorbidity ,and insurance payer status, with healthcare utilization and in-hospital complications (infection, transfusion, and revision surgery) after TAA. We calculated odds ratio (OR) and 95% confidence intervals (CI). RESULTS: The cohort consisted of 6280 TAAs with a mean age of 62 years; 52% were female, 70% White, and 62% had osteoarthritis as the underlying diagnosis. Compared to age < 50 years, older age categories had higher ORs of total hospital charges above the median, length of hospital stay above the median (>2 days) and discharge to a rehabilitation facility, 1.26-19.41, and a lower OR of in-hospital infection, 0.07-0.09. Compared to Whites, Blacks had higher OR (95% CI) of: discharge to a rehabilitation facility, 1.45 (1.06, 1.98); length of hospital stay >2 days, 2.21 (1.37, 3.57); in-hospital transfusion, 4.39 (1.87, 10.30); and in-hospital revision, 8.25 (1.06, 64.21); and Hispanics were more likely to have total hospital charges above the median, OR 1.49 (1.10, 2.02), and infection, 9.30 (1.27, 68.05). Higher comorbidity and Medicare payer status were each associated with higher ORs of healthcare utilization, ORs ranging 1.20-2.57 and 1.74-2.19, respectively. CONCLUSIONS: Age, race/ethnicity, comorbidity, and insurance payer status were independently associated with post-TAA outcomes. Further insight into modifiable mediators of these associations can pave the way for improving these outcomes in the future.Key Points• Older age was associated with higher healthcare utilization post-ankle arthroplasty.• Compared to Whites, Blacks or Hispanics had higher healthcare utilization and in-hospital complications post-ankle arthroplasty.• Higher comorbidity and Medicare payer status were each associated with higher healthcare utilization post-ankle arthroplasty.

Total Ankle Arthroplasty Survival and Risk Factors for Failure.

BACKGROUND: Total ankle arthroplasty (TAA) is an increasingly selected treatment for end-stage ankle arthritis; however, failure and revision of the tibial and talar components remains an issue. Although multiple risk factors have been shown to contribute to early component revision, no study has looked at combining such risk factors into a predictive model that could potentially decrease revision rates and improve implant survival. This study aimed to develop a predictive model for TAA failure based on patient characteristics, patient-reported outcomes (PROs), and immediate postoperative radiographs. METHODS: A retrospective review of a single-site ankle arthritis database was conducted. All patients with current-generation ankle replacements including the Hintegra and Infinity prostheses implanted between 2004 and 2015 and with complete postoperative radiographs taken between 6 and 12 weeks postoperatively were included. Eight coronal and sagittal radiographic parameters were assessed and performed twice by 2 independent orthopedic surgeons on included TAAs. These radiographic parameters were then analyzed in association with patient demographics and PRO. Advanced statistical methods including survival analysis were used to construct a predictive model for TAA survival. A total of 107 patients were included and analyzed with a median clinical follow-up of 49 months (minimum 24 months). RESULTS: A predictive model was created, with 4 parameters identified as being statistically associated with TAA metal-component revision: diabetes mellitus, poor baseline Ankle Osteoarthritis Scale (AOS) score, excessively dorsiflexed talar component, and an anteriorly/posteriorly translated talus relative to the tibial axis. The presence of 3 parameters predicted TAA survival of 0.60 whereas presence of all 4 parameters predicted survival of only 0.13 in the period studied. CONCLUSION: Our predictive model is based on a combination of patient factors, PROs, and radiographic TAA alignment. We believe it can be used by surgeons to predict failure in their TAA patients, thereby optimizing postoperative outcomes by improving patient selection and modifiable outcome-specific parameters. LEVEL OF EVIDENCE: Level III, retrospective cohort study using prospectively collected data.

The Effect of Patient Characteristics on 1 to 2-Year and Minimum 5-Year Outcomes After Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty has shown durable improvements in patient-reported outcomes. However, the impact of common comorbidities and patient factors has not been fully characterized. The purpose of this study was to identify patient comorbidities and characteristics that impact outcomes after total ankle arthroplasty. METHODS: Patients who underwent a total ankle arthroplasty between January 2007 and December 2016 were enrolled into a prospective study at a single academic center. Patients completed outcome measures before the surgical procedure and at the time of follow-up: a visual analog scale (VAS) for pain, the 36-item Short Form Survey (SF-36), and the Short Musculoskeletal Function Assessment (SMFA). Patient and operative factors, along with prevalent preoperative comorbidities, were analyzed for association with preoperative to postoperative changes in 1 to 2-year and minimum 5-year outcomes. Comorbidities that met a significance threshold of p < 0.05 in adjusted analyses were incorporated into multivariable outcome models. RESULTS: A total of 668 patients with a mean 1 to 2-year follow-up (and standard deviation) of 1.6 ± 0.5 years (range, 10 months to 2 years and 2 months) were included. Patients' pain and function significantly improved across all outcomes (p < 0.05). However, depression, staged bilateral ankle arthroplasty, increased length of stay, a prior surgical procedure, increased American Society of Anesthesiologists (ASA) score, and particular implant types were associated with significantly smaller improvements in at least 1 patient-reported outcome after total ankle arthroplasty in the 1 to 2-year follow-up, although the effects were relatively small. At a minimum 5-year follow-up, smoking, depression, implant type, and staged bilateral ankle arthroplasty were associated with worse outcomes, and a prior surgical procedure, a simultaneous bilateral surgical procedure, and obesity were associated with improved outcomes. CONCLUSIONS: Patients who underwent total ankle arthroplasty had significant improvement in patient-reported outcomes, although several factors were associated with a small, but significant, negative impact on improvement, including depression, increased ASA score, current smoking, increased length of stay, a prior surgical procedure, and staged bilateral total ankle arthroplasty. Current smoking, obesity, and depression are potentially modifiable risk factors that could be improved prior to total ankle arthroplasty. Patients with these characteristics should be counseled on their risk of limited improvement in ankle pain and disability after total ankle arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Survivorship and long-term outcome of a consecutive series of 200 Scandinavian Total Ankle Replacement (STAR) implants.

AIMS: We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants. PATIENTS AND METHODS: Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan-Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year. RESULTS: A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up. CONCLUSION: STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty.

Surgeon Type and Outcomes After Inpatient Ankle Arthrodesis and Total Ankle Arthroplasty: A Retrospective Cohort Study Using the Nationwide Premier Healthcare Claims Database.

BACKGROUND: Two main treatments for end-stage ankle arthritis are ankle arthrodesis and total ankle arthroplasty (TAA). While both procedures can be performed either by a foot and ankle orthopaedic surgeon or a podiatrist (when within a particular state's scope of practice), studies comparing the surgical outcomes of the 2 surgeon types are lacking. Therefore, in this study, we compared outcomes by surgeon type for TAA and for ankle arthrodesis. METHODS: This retrospective cohort study utilized data from the nationwide Premier Healthcare claims database (2011 to 2016) regarding TAA (n = 3,674) and ankle arthrodesis (n = 4,980) procedures. Multivariable models estimated associations between surgeon type (podiatrist versus orthopaedic foot and ankle surgeon) and opioid utilization (in oral morphine equivalents [OMEs]), length of stay, and cost of hospitalization. We report percent change (compared with reference) and 95% confidence intervals (CIs). RESULTS: Overall, 76.5% (n = 2,812) and 18.8% (n = 690) of TAA procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 4.7% (n = 172). For ankle arthrodesis, 75.3% (n = 3,752) and 18.3% (n = 912) of the procedures were performed by orthopaedic foot and ankle surgeons and podiatrists, respectively; surgeon type was unknown for 6.3% (n = 316). The proportion of TAA and ankle arthrodesis procedures performed by podiatrists increased over time, from 12.8% and 13.6% in 2011 to 24.6% and 26.0% in 2016, respectively. When adjusting for relevant covariates, procedures performed by podiatrists (compared with orthopaedic foot and ankle surgeons) were associated with increased length of stay: for TAA, +16.7% (95% CI, 7.6% to 26.5%; median, 2 days in both groups) and for ankle arthrodesis, +14.2% (95% CI, 7.9% to 20.9%; median, 3 compared with 2 days) (p < 0.05 for both). In addition, ankle arthrodesis performed by podiatrists was associated with increased cost of hospitalization: +28.5% (95% CI, 22.1% to 35.2%; median, $19,236 compared with $13,433) (p < 0.05). Differences in opioid utilization were nonsignificant in the main analysis: +10.9% (95% CI, -3.1% to 26.8%; median, 345 compared with 250 OMEs) and +2.8% (95% CI, -5.9% to 12.4%; median, 351 compared with 315 OMEs) for TAA and ankle arthrodesis, respectively. CONCLUSIONS: An increasing trend in the proportion of procedures performed by podiatrists was coupled with apparent increases in length of stay and cost compared with procedures performed by orthopaedic foot and ankle surgeons. Given the increasing demand for these procedures, factors associated with resource utilization, such as type of surgeon, may be increasingly important on the population level. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Failure of Total Ankle Arthroplasty With a Minimum Five Years of Follow-up.

BACKGROUND:: As the popularity of total ankle arthroplasty (TAA) increases and indications expand, surgeons require a better understanding of which patient factors are associated with implant failure. In this study, we aimed to use a large total ankle database to identify independent risk factors for implant failure at mid- to long-term follow-up. METHODS:: A prospectively collected database was used to identify all patients who underwent primary TAA with a minimum 5 years' follow-up. The primary outcome was revision, defined as removal of one or both metal components; failures due to infection were excluded. Patient and clinical factors analyzed included age, sex, body mass index (BMI), smoking status, presence of diabetes, indication for TAA, implant, tourniquet time, and presence of ipsilateral hindfoot fusion. Preoperative coronal deformity and sagittal talar translation were assessed, as were postoperative coronal and sagittal tibial component alignment. Univariable and multivariable analyses were performed to identify predictors of implant failure. After excluding 5 ankles that failed because of deep infection, 533 ankles with a mean 7 (range, 5-11) years of follow-up met the inclusion criteria. Four implants were used: INBONE I, INBONE II, STAR, and Salto-Talaris. RESULTS:: Thirty-four ankles (6.4%) were revised or removed a mean 4 (range, 1-9) years postoperatively. The only independent predictors of failure were the INBONE I prosthesis and ipsilateral hindfoot fusion ( P = .006 and P = .023, respectively). CONCLUSIONS:: This is among the largest studies to analyze the relationship between TAA failure rates and multiple different patient, operative, and radiographic factors. Of note, age, BMI, and amount of deformity were not associated with higher failure rates. Only patients with ipsilateral hindfoot fusion or who received the INBONE I prosthesis were at significantly higher risk of implant failure. LEVEL OF EVIDENCE:: Level III, retrospective cohort study.

Patient and Practice Trends in Total Ankle Replacement and Tibiotalar Arthrodesis in the United States From 2007 to 2013.

INTRODUCTION: Both total ankle replacement (TAR) and tibiotalar arthrodesis (TTA) are used in the surgical management of ankle arthritis. Over the past decade, TAR instrumentation, techniques, and implants have improved, making the procedure more reliable and reproducible, thus making TAR more common. METHODS: The Nationwide Inpatient Sample database from 2007 to 2013 was used to obtain data on patients elder than 50 years who underwent either TAR or TTA. Differences in temporal, demographic, and diagnosis trends between TAR and TTA were analyzed. RESULTS: Between 2007 and 2013, 15,060 patients underwent TAR and 35,096 underwent TTA. Patients undergoing TTA had significantly more comorbidities (2.17 versus 1.55; P < 0.001). The share of TAR performed increased significantly from 2007 (14%) to 2013 (45%) (P < 0.001). From 2007 to 2013, we found a 12-fold increase in the odds of having a TAR for patients with posttraumatic osteoarthritis (P < 0.001), a 4.9-fold increase for those with primary osteoarthritis, and a 3.1-fold increase for patients with rheumatoid arthritis (P < 0.001). CONCLUSIONS: Over the past decade, the frequency of TAR has increased, particularly in patients with posttraumatic arthritis and osteoarthritis. Surgeons still perform TAR in healthier patients compared with TTA; however, because surgeons become more experienced with the technique, patients are undergoing TAR at a markedly higher rate. LEVEL OF EVIDENCE: Level III: retrospective comparative study.

Improvement of Outcomes During the First Two Years Following Total Ankle Arthroplasty.

BACKGROUND: Many studies of total ankle arthroplasty (TAA) have focused on the range of motion and functional outcomes at the time of intermediate-term follow-up. The purpose of our study was to analyze the progression of ankle hindfoot range of motion and patient-reported measures through the first 2 years following TAA. METHODS: The charts of 134 patients who had been treated with a TAA by a single surgeon were retrospectively reviewed, and 107 (109 TAAs) were included in the study. The overall range of motion in the sagittal plane was measured as the change in the position of the tibia relative to the floor on dedicated weight-bearing lateral radiographs made with the ankle in maximum plantar flexion and dorsiflexion preoperatively and at 3 months, 6 months, 1 year, and 2 years postoperatively. In addition, patients completed a visual analogue scale (VAS) for pain, the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sports Subscales, and the Short Form-12 (SF-12) Physical (PCS) and Mental (MCS) Component Summary scores at each time interval. RESULTS: The mean overall range of motion in the sagittal plane was 20.7° preoperatively and improved to 28.3°, 34.3°, 33.3°, and 33.3° at 3 months, 6 months, 1 year, and 2 years, respectively (p < 0.001). At each postoperative time point, the median VAS score was improved (p < 0.001) compared with the preoperative VAS score. Similarly, the FAAM and SF-12 scores were improved, compared with the preoperative score, at 6 months and later (p < 0.001). An increased range of motion correlated with a lower VAS score preoperatively (ρ = -0.31, p = 0.035) and at 1 year (ρ = -0.36, p = 0.003) postoperatively. An increased range of motion correlated with a higher FAAM ADL score at 3 months (ρ = 0.50, p = 0.012), 1 year (ρ = 0.26, p = 0.040), and 2 years (ρ = 0.39, p = 0.003) postoperatively. CONCLUSIONS: Patients who underwent TAA had improvement, compared with preoperatively, in the overall sagittal plane range of motion up to 6 months and maintained improvement in pain and function scores up to 2 years. Pain scores remained improved throughout the 2-year follow-up period. A better range of motion was correlated with less pain as measured with the VAS. An increased range of motion postoperatively was correlated with better function as measured with the FAAM. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Recent National Trends and Outcomes in Total Ankle Arthroplasty in the United States.

Total ankle arthroplasty (TAA) is an evolving option for treating ankle arthritis. We assessed the national trends in usage and perioperative outcomes of TAA in the United States. International Classification of Diseases, 9th revision (ICD-9), codes were used to search the National Hospital Discharge Survey database for TAA from 1997 to 2010. Patient demographics, comorbidities, hospitalization length, discharge disposition, blood transfusion, lower extremity deep vein thrombosis, pulmonary embolism, and mortality data were gathered. Trends were evaluated using linear regression with Pearson's correlation coefficient, and statistical comparisons were performed using Student's t test and z-test for proportions with significance at p = .05. We identified 120 patients with TAA. TAA demonstrated a positive correlation with time (r = 0.57), significantly increasing from 2.4 cases per 100,000 admissions from 1997 to 2003 to 3.5 cases per 100,000 from 2004 to 2010 (p = .04). The mean age was 57.8 (range 19 to 83) years. The mean number of comorbidities was 4.5 (range 1 to ≥7). Although patient age remained stable (p = .21), the mean number of comorbidities significantly increased from 4.0 from 1997 to 2003 to 4.8 from 2004 to 2010 (p = .02); 8 patients (6.7%) had diabetes, 71 (59.2%) had primary osteoarthritis, and 35 (29.2%) had posttraumatic arthropathy. The mean length of stay significantly decreased from 3.1 to 2.3 days (p = .03). Three patients (2.5%) required a blood transfusion. No deep vein thrombosis or PE was diagnosed. No patients died during the operative admission; 95 patients (87%) were discharged home and 14 (13%) required a skilled rehabilitation facility. Discharge patterns showed no significant change with time (p = .59). Usage of TAA in the United States has increased nearly 50% over the past 14 years. TAA was associated with shorter hospitalization, infrequent rehabilitation facility requirements, and few perioperative complications.

Surgical Complications of Ankle Joint Arthrodesis and Ankle Arthroplasty Procedures.

Total ankle arthroplasty (TAA) and ankle arthrodesis (AA) are complicated surgeries that carry a learning curve with them. Complications are an aspect of all surgeries that must be considered. Surgeons must be prepared to handle these complications. The most important things are early identification and treatment of these complications. Treating complications is a combination of medicines, conservative measures, and most importantly surgical intervention. Recent studies have shown a decrease in complications of TAA and AA over the past 10 years. Carefully identifying the complications early and treating patients right away are imperative to increasing the outcomes for these patients.

Is There Anything to Learn from a National Joint Registry?

National joint registries (NJRs) have been established in Northern Europe for over 20 years. Since then, many other countries have begun collecting and reporting national data for total ankle arthroplasty (TAA). With relatively small numbers implanted, a large variety of available designs, and with any long-term reports dominated by designer groups, TAA is ideally placed to benefit from large national or even pooled national registries. This article reviews the existing registry-based literature with respect to what is already known. The potential positives and down sides of registry data also are highlighted.

Effect of Insurance on Rates of Total Ankle Arthroplasty Versus Arthrodesis for Tibiotalar Osteoarthritis.

BACKGROUND: Several studies have examined the effect of insurance on the management of various orthopedic conditions. The purpose of our study was to assess the effect of insurance and other demographic factors on the operative management of tibiotalar osteoarthritis. METHODS: The National Inpatient Sample (NIS) database was used to identify patients who underwent a total ankle arthroplasty (TAA) or tibiotalar arthrodesis (TTA) for tibiotalar osteoarthritis. Insurance status was identified for each patient, and the proportions of each insurance type were computed for each operative modality. A multivariate analysis was performed to account for confounding variables to isolate the effect of insurance type on operative treatment. RESULTS: From 2007 to 2012, a total of 10 010 patients (35.6%) were identified who underwent a total ankle replacement (TAR) procedure and 18 094 patients (64.4%%) who underwent TTA for tibiotalar osteoarthritis. Patients receiving a TAR were older (65.8 vs 64.2, P < .001), more likely to be female (54% vs 51%, P < .001), and had fewer comorbidities (4.2 vs 4.5, P < .001) than patients who underwent a TTA. After controlling for baseline differences, patients with Medicare (odds ratio [OR] 3.00, P < .001), and private insurance (OR 3.19, P < .001) were approximately 3 times more likely to undergo TAR than patients with Medicaid. CONCLUSIONS: Patients with tibiotalar osteoarthritis were more likely to receive a TAR procedure if they had Medicare or private insurance compared with patients who had Medicaid. Further research should be done to better understand the drivers of this phenomenon if equitable care is to be achieved. LEVEL OF EVIDENCE: Level II, prognostic study.

The Regionalization of Total Ankle Arthroplasties and Ankle Fusions in New York State: A 10-Year Comparative Analysis.

BACKGROUND: Total ankle arthroplasty (TAA) provides an alternative to ankle fusion (AF). The purpose of this study is to (1) determine the extent of TAA regionalization, as well as examine the growth of TAA performed at high-, medium-, and low-volume New York State institutions and (2) compare this regionalization and growth with AF. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) administrative data were used to identify 737 primary TAA and 7453 AF from 2005 to 2014. The volume of TAA and AF surgery in New York State was mapped according to patient and hospital 3-digit zip code. RESULTS: The number of TAA per year grew 1500% (from 11 to 177) from 2005 to 2014, while there was a 35.6% reduction (from 895 to 576) in yearly AF procedures. TAA recipients were widely distributed throughout the state, while TAA procedures were regionalized to a few select metropolitan centers. AF procedures were performed more uniformly than TAA. The number of TAA has continued to increase at high- (15 to 91) and medium-volume (14 to 67) institutions where it has decreased at low-volume institutions (44 to 19). CONCLUSION: The increased utilization of TAA is attributed to relatively few high-volume centers located in major metropolitan centers. LEVELS OF EVIDENCE: Level IV: well-designed case-control or cohort studies.