Trends in arthrodeses and total joint replacements in Foot and Ankle surgery in Germany during the past decade-Back to the fusion?

BACKGROUND: The goal of this study was to analyze trends in Foot and Ankle surgery in Germany during the past ten years. METHODS: Data of the German Federal Statistical Office from 2008 until 2018 were screened. We focused on the analysis of fusions and total joint replacements. RESULTS: The total amount of the surgeries increased (+39.5%). Especially fusions like arthrodesis of the ankle (+31%) and of the MTP-1 joint (+77%) were on the rise. In 2017 60% of ankle arthrodesis were conducted in men, while 69% of MTP-1 arthrodesis were performed in women. The amount of joint replacements showed a decline during the last decade, in TAR (-39%) and in the MTP-1 (-48%). Regarding the patients age while undergoing a TAR, we observed a shift of the peak age group from 65 to 70 years in 2008 towards 55-60 years in 2017. CONCLUSION: Our study represents actual health care reality in Germany and shows a constant increase of ankle arthritis surgeries in the last decade, while there was a massive shift regarding the ratio of TAR in favour of fusion procedures.

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.

Response to review article published titled 'Total ankle arthroplasty versus ankle arthrodesis - a comparison of outcomes over the last decade'.

We write in response to Lawton et al.'s (J Orthop Surg Res 12:76, 2017) important systematic review comparing the outcomes of total ankle replacement (TAR) and ankle arthrodesis (AA) after reviewing the existing literature. Traditionally, AA was the gold standard treatment for ankle osteoarthritis but there is renewed interest in TAR given modern design advantages of preserved ankle motion and gait. We outline some pertinent issues for surgeons to consider when interpreting results from review articles comparing treatment types given the limitations of primary studies. These include significant clinical heterogeneity from the indication for surgery, different treatment type subgroups and from poorly defined clinical outcomes.

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.

Complex Total Ankle Arthroplasty.

Total ankle arthroplasty is a viable surgical technique for the treatment of end-stage degenerative joint disease. With continued advancement in prosthetic design, refined surgical techniques, and improved outcomes, the indications for total ankle replacement have expanded to include cases of increasing complexity. With meticulous preoperative planning and exacting execution, many frontal plane deformities and cases of avascular necrosis can now be successfully addressed at the time of prosthesis implantation or in a staged procedure.

Time trends and risk factors for perioperative complications in total ankle arthroplasty: retrospective analysis using a national database in Japan.

BACKGROUND: Total ankle arthroplasty (TAA) has become increasingly popular worldwide as an alternative to ankle arthrodesis for surgical treatment of end-stage ankle arthritis. The aim of this epidemiological study, using a national inpatient database in Japan, was to describe the volume, utilization, patient characteristics, and temporal trends regarding these procedures in Japan, and to identify the risk factors associated with perioperative adverse events in TAA. METHODS: This was a population-based, retrospective cohort study. We retrospectively identified 2775 patients in the Diagnosis Procedure Combination database who underwent ankle arthrodesis or TAA for ankle arthritis at 559 hospitals in Japan from 2007 to 2013. Information on sex, age, main diagnosis, use of blood transfusion, duration of anesthesia, length of hospital stay, in-hospital mortality, hospitalization costs, additional procedures after primary surgery, and use of negative pressure wound therapy was extracted. Multivariable logistic regression analysis was performed to analyze the effect of various factors on the incidence of perioperative adverse events in TAA, including additional procedure during hospitalization, negative pressure wound therapy, blood transfusion, and in-hospital death. RESULTS: We identified 465 patients who underwent TAA and 2310 patients who underwent ankle arthrodesis. There was no apparent increase in the proportion of TAAs performed during the survey period. Patients undergoing TAA tended to be older, female, and have rheumatoid arthritis compared with those undergoing ankle arthrodesis. Patients undergoing TAA had shorter length of stay, higher hospitalization costs, and more blood transfusions compared with those undergoing ankle arthrodesis. Lower hospital volume and shorter anesthesia time were associated with higher rates of adverse events after TAA. CONCLUSIONS: Despite an increase in the popularity of TAA internationally, the number of TAAs performed remains low in Japan. Lower hospital volume and anesthesia time were associated with higher rates of perioperative adverse events after TAA. LEVEL OF EVIDENCE: IV, Cross-sectional study.

[The latest treatment of the forefoot and ankle of the patients with rheumatoid arthritis].

Operative therapy for the foot and ankle disorders of rheumatoid arthritis (RA) have been changing with advances in drug therapy. The surgical techniques, joint-preserving procedure for the RA foot and total ankle arthroplasty for the RA ankle, are the surgical techniques which allow patients with RA not only to relief their pain but also obtain higher lower limb function. Recently, more and more patients with RA have been receiving joint-preserving procedure for the foot or total ankle arthroplasty for the ankle. Therefore, in this article, we would like to describe surgical therapy for the lower limb of patients with RA.

Epidemiology of Total Ankle Arthroplasty: Trends in New York State.

The rate of total ankle arthroplasty (TAA) is increasing in the United States as its popularity and indications expand. There currently is no national joint registry available to monitor outcomes, and few studies have addressed the challenges faced with TAA. The purpose of this study was to evaluate the incidence, complications, and survival rates associated with TAA using a large statewide administrative discharge database. Individuals who underwent primary TAA from 1997 to 2010 were identified in the Statewide Planning and Research Cooperative System database from the New York State Department of Health. The age, sex, comorbidities, state of residence, primary diagnosis, and readmissions within 90 days were analyzed for patients with an ICD-9-CM procedure code of 81.56 (TAA). Failure of a TAA implant was defined as revision, tibiotalar arthrodesis, amputation, or implant removal. During the 14-year period, 420 patients underwent 444 TAAs (mean patient age of 61 years, 59% women, mean Charlson-Deyo comorbidity score of 0.45, and 86% New York State residents). The primary diagnosis was 37.4% osteoarthritis, 34.3% traumatic arthritis, and 15.5% rheumatoid arthritis. Surgery for failure was associated only with a younger age (56.5 vs 62 years, P=.005). The rate of subsequent failure procedures following TAAs performed in New York State was 13.8%. The incidence of TAAs is steadily increasing. The overall survival rate in New York State is better than rates reported in other national registries, but it is not yet comparable to those of hip and knee replacements. [Orthopedics. 2016; 39(3):170-176.].

Time trends in total ankle arthroplasty in the USA: a study of the National Inpatient Sample.

The objective of this study was to assess the time trends in utilization, clinical characteristics, and outcomes of patients undergoing total ankle arthroplasty (TAA) in the USA. We used the Nationwide Inpatient Sample (NIS) data from 1998 to 2010 to examine time trends in the utilization rates of TAA. We used the Cochran Armitage test for trend to assess time trends across the years and the analysis of variance (ANOVA), Wilcoxon test, or chi-squared test (as appropriate) to compare the first (1998-2000) and the last time periods (2009-2010). TAA utilization rate increased significant from 1998 to 2010: 0.13 to 0.84 per 100,000 overall, 0.14 to 0.88 per 100,000 in females, and from 0.11 to 0.81 per 100,000 in males (p < 0.0001 for each comparison for time trends). Compared to the 1998-2000 period, those undergoing TAA in 2009-2010 were older (41% fewer patients <50 years, p < 0.0001), less likely to have rheumatoid arthritis as the underlying diagnosis (55% fewer patients, p = 0.0001), more likely to have Deyo-Charlson index of 2 or more (197% more, p = 0.0010), and had a shorter length of stay at 2.5 days (17% reduction, p < 0.0001). Mortality was rare ranging from 0 to 0.6% and discharge to inpatient facility ranged 12.6-14.1%; we noted no significant time trends in either (p > 0.05). The utilization rate of TAA increased rapidly in the USA from 1998 to 2010, but post-arthroplasty mortality rate was stable. Underlying diagnosis and medical comorbidity changed over time and both can impact outcomes after TAA. Further studies should examine how the outcomes and complications of TAA have evolved over time.

[Research progress on total ankle replacement].

Total ankle replacement (TAR) is considered as a treatment option for end stage ankle arthritis. This treatment was abandoned due to the early failure prosthesis in the past. However, with recently advancements in ankle prosthesis design and improved surgical techniques, TAR has made great progress and the indications are expanding. Many studies have shown acceptable mid term and long term results of TAR, and it is worth looking forward to the prospect. Advantages of TAR over arthrodesis include improvement in joint range of motion, better gait activity, and decreased incidence of adjacent joint arthritis. With the further development, TAR will be considered as gold standard for the treatment of end stage ankle arthritis instead of the ankle arthrodesis. However, there are still many problems of TAR need to be solved in this present stage of development, including higher economic costs, lower survival rate, and higher revision rate. Patients and surgeons should have confidence in TAR, also need to choose this treatment with careful consideration.

[Knee and ankle arthroplasty ­ What results can be expected?]. / Knie- und Sprunggelenksprothese - Was darf der Patient erwarten?

Osteoarthrits is listed number one reason for adult disability. Therefore treatment of arthritis has maximum impact for the general practitioner. Disability of knee and ankle osteoarthritis causes inability to work and loss of independence. Patients will ask their physicians about expectations after total knee or ankle arthroplasty when other treatment has failed. The satisfaction rate after knee prosthesis is 75 ­ 89 % and for total ankle arthroplasty even slightly higher at 79 ­ 97 %. This is surprising because the survival in joint registry data after knee arthroplasty is 94 % compared to ankle arthroplasty significantly less at 69 % after 10 years, when a component revision is used as endpoint. In addition, knee component revision usually means exchanging to knee revision prosthesis while at the ankle it is usually prosthetic removal and conversion to ankle fusion. This difference of satisfaction is probably caused by the fact that knee arthroplasty is a standard operation and patients have very high expectations. Key to this is realistic patient education before surgery by general practitioners and specialists about the typical postoperative course with significant pain reduction not within days but rather in the first 2 postoperative years with moderate activity allowed. Candidates for total ankle replacement must be carefully selected because the prosthesis relies on a good bone stock, stable ligaments and proper limb alignment. Unlike for the knee, none of these can currently be corrected by the ankle prosthesis itself. Patients can expect significant pain reduction, better function and a slight improved range of motion after knee and ankle prosthesis. Sports activities are possible, but should be in a low-impact area. Heavy physical work or running and jumping activities are usually not possible and surely not recommended due to increased wear.

Total ankle replacement--evolution of the technology and future applications.

Total ankle arthroplasty was developed to reduce pain and retain motion of the ankle joint in patients with osteoarthritis much like its total hip and knee counterparts. Orthopaedic surgeons are well equipped to evaluate and treat patients with end-stage hip or knee arthritis; however, the management of patients with ankle arthritis represents a challenge to both general orthopaedic surgeons and to the foot and ankle surgeons to whom these patients are often referred. Although techniques for both hip and knee arthroplasty have evolved to provide long-term pain relief and functional improvement, neither ankle arthrodesis nor arthroplasty has demonstrated comparably favorable outcomes in long-term follow-up studies. Early ankle arthroplasty designs with highly constrained cemented components were abandoned due to unacceptably high failure rates and complications. While arthrodesis is still considered the "gold standard" for treatment of end-stage ankle arthritis, progression of adjacent joint arthrosis and diminished gait efficiency has led to a resurgence of interest in ankle arthroplasty. Long-term outcome studies for total ankle replacement found excellent or good results in 82% of patients who received a newer generation ankle device compared with 72% if undergoing ankle fusion. Continued long-term follow-up studies are necessary, but total ankle arthroplasty has become a viable option for surgical treatment of ankle arthritis.

Registry data trends of total ankle replacement use.

Joint arthroplasty registry data are meaningful when evaluating the outcomes of total joint replacement, because they provide unbiased objective information regarding survivorship and incidence of use. Critical evaluation of the registry data information will benefit the surgeon, patient, and industry. However, the implementation and acceptance of registry data for total ankle replacement has lagged behind that of hip and knee implant arthroplasty. Currently, several countries have national joint arthroplasty registries, with only some procuring information for total ankle replacement. We performed an electronic search to identify publications and worldwide registry databanks with pertinent information specific to total ankle replacement to determine the type of prostheses used and usage trends over time. We identified worldwide registry data from 33 countries, with details pertinent to total ankle replacement identified in only 6 countries. The obtained information was arbitrarily stratified into 3 distinct periods: 2000 to 2006, 2007 to 2010, and 2011. Within these study periods, the data from 13 total ankle replacement systems involving 3,980 ankles were identified. The vast majority (97%) of the reported ankle replacements were 3-component, mobile-bearing, uncemented prostheses. Three usage trends were identified: initial robust embracement followed by abrupt disuse, minimal use, and initial embracement followed by sustained growth in implantation. Before the widespread acceptance of new total ankle replacements, the United States should scrutinize and learn from the international registry data and develop its own national joint registry that would include total ankle replacement. Caution against the adoption of newly released prostheses, especially those without readily available revision components, is recommended.

Comparison of practice patterns in total ankle replacement and ankle fusion in the United States.

BACKGROUND: Although tibiotalar fusion has historically been considered the gold standard treatment for end-stage arthritis of the ankle, the performance of total ankle replacement appears to be gaining favor as improved outcomes have been observed with new implant designs and surgical techniques. The purpose of this study was to compare trends and demographics in the performance of ankle fusion and total ankle replacement in the United States. METHODS: The Current Procedural Terminology (CPT) codes of patients undergoing ankle fusion and total ankle replacement were searched using the PearlDiver Patient Record Database, a national database of orthopaedic patients. The CPT codes for open ankle arthrodesis (27870), arthroscopic ankle arthrodesis (29899), and total ankle replacement (27700, 27702) were searched for the years 2004 to 2009 to identify relative changes in the performance of ankle fusion and replacement over time. RESULTS: The performance of ankle fusion was unchanged during the 6-year study period. In contrast, an increase in total ankle replacement was observed, from 0.63 cases per 10 000 patients searched in 2004 to 0.99 cases per 10 000 patients in 2009 (P < .05). Both ankle fusion and total ankle replacement were performed most commonly in patients aged 60 to 69 years (P < .05). Although an even gender distribution was observed in patients undergoing total ankle replacement, open and arthroscopic fusion were more commonly performed in males (P < .05). With regard to regional distribution, open and arthroscopic fusion were most commonly performed in the western region of the United States, whereas total ankle replacement was performed most frequently in the Midwest (P < .001). CONCLUSIONS: In the population studied, the performance of total ankle replacement increased 57% from 2004 to 2009 and was performed equally in male and female patients when compared to ankle fusion, which was more often performed in males and was unchanged with time. LEVEL OF EVIDENCE: Level IV, cross-sectional study.