Are Complications and Survival of Total Ankle Arthroplasty Influenced by Hospital Setting? An Analysis of 189 Cases Performed in Community and County Hospitals

Abstract

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Total ankle arthroplasty is a notoriously challenging operation typically reserved for well-resourced academic tertiary care facilities. Limited studies support its safety in a community hospital setting, while outcomes in a county hospital setting have not been previously described. Demonstrating that TAA can be performed effectively and safely in broader hospital settings is critical given the importance of access to care, the prevalence of tibiotalar arthritis, and known efficacy of TAA for pain management, ankle stability, and preservation of functional ambulation. The purpose of this study was to investigate the differences in post-operative complications, revision rates, and implant survival of TAA performed in the community versus county hospital setting. Methods: A total of 189 patients that underwent TAA between January 2014 and May 2021 were retrospectively evaluated. 149 cases (79%) were performed in a community hospital setting, and 40 cases (21%) were performed in a county hospital setting. Surgeries were completed by a single fellowship-trained surgeon utilizing the same Stryker STAR implant for all cases. Patient demographics, postoperative complications, and revision surgery profiles were collected with a mean follow-up of 22.3 +- 21.1 months. Logistic regression was used to analyze the relationships between complications and osteoarthritis etiology, age, smoking history, diabetes, obesity, and hospital setting. Categorical variables were compared with Chi-square tests, means were compared with a two-tailed Student's t-test, and implant survival was assessed with a Kaplan-Meier analysis. Significance was defined as p<.05 for all statistical analyses. Results: Controlling for osteoarthritis etiology and patient demographics, TAA performed in the county setting was a significant predictor of aseptic loosening (b=2.25, SE=1.01, p=.025; OR=9.5, 95% CI: 1.3-68.1) and posterior tibial tendon (PTT) dysfunction (b=2.76, SE=1.3, p=.034; OR=16, 95% CI: 1.2-204). Rate of aseptic loosening was significantly higher in the county as compared to the community setting (10% vs. 1.3%) (p=.006), as was PTT dysfunction (10% vs. 0.7%) (p=.001). All other complications were comparable between settings (p>.05) (Figure 1). At 7 years, TAA survival with any reoperation as an endpoint was comparable between community (88.6%) and county (87.5%) settings (p=.872), with no difference in mean time to reoperation between community (11.2 months) and county (22.3 months) settings (p=.25). With explant surgery as an endpoint, survival was similarly comparable between community (97.3%) and county (95%) settings (p=.677). Overall mean time to explant surgery was 24.4 months with no difference between settings (p=.10). Conclusion: Total ankle arthroplasty has a similar reoperation rate and implant survival in community and county hospital settings. Our mid-term results compare favorably with outcomes reported from academic tertiary care facilities and suggest that total ankle arthroplasty is an effective intervention across hospital settings when performed by an experienced surgeon. However, certain complications, including symptomatic aseptic loosening and PTT dysfunction, were found to be more common when performed in the county hospital setting. Future studies are necessary to investigate the impact of the increased complication rate on long-term outcomes of total ankle arthroplasty in the county hospital setting.