Management Of End-stage Ankle Arthritis Research Articles

The Effect of Diabetes Mellitus on Total Ankle Arthroplasty Outcomes

Category: Ankle Arthritis; Ankle Introduction/Purpose: The utility of total ankle arthroplasty (TAA) for management of end-stage ankle arthritis continues to increase. Postoperative infection after TAA is a devastating complication leading to additional surgeries, hospitalizations, long term antibiotics, arthrodesis, and sometimes amputation. Diabetes has been shown to be associated with postoperative infections following other orthopedic procedures. While the majority of literature demonstrates an association between diabetes and post- operative complications following TAA, other studies have demonstrated no such association. The goal of this study was to determine if diabetes influences the outcomes following TAA. Methods: An insurance database was utilized to identify patients undergoing TAA for end-stage ankle arthritis with a concurrent diagnosis of diabetes based on CPT, ICD-9, and ICD-10 diagnosis and procedure codes from 2010 to 2021. The postoperative outcomes of all cause revision, periprosthetic joint infection, periprosthetic joint infection with revision, and aseptic revision were compared between diabetic and nondiabetic patients with a minimum 2-year follow up using Kaplan-Meier and Cox proportional hazards analyses. Patient demographics, comorbidities, and Charlson Comorbidity Index was queried and analyzed via univariate and multivariate analysis, along with 90-day postoperative outcomes. Results: The study population included 8,317 patients who underwent TAA, 345 of which had a concurrent diagnosis of diabetes, with a minimum of 2-year follow up from 2010 to 2021. After multivariate Cox proportional hazards analysis, the 5-year cumulative incidence of PJI was 7.3% in diabetic patients compared to 3.9% in nondiabetic patients, with a 95% increased risk of revision (HR 1.95, 95% CI: 1.15-3.30, P=0.01). Diabetic patients also demonstrated a 5-year cumulative incidence of septic revision rate of 1.4% compared to 0.4% in nondiabetic patients, with a 363% increased risk (HR 4.63, 95% CI: 1.22-17.52, P=0.02). After controlling for differences in demographics and comorbidities through multivariate analysis, diabetes was independently associated with an increased risk for stroke (OR 10.12, P=0.007). Conclusion: The incidence of post-operative complications, including increased risk of 5-year risk of periprosthetic joint infection and septic revision was higher among diabetic patients compared to nondiabetic patients.

Factors Predictive of Early Complications Following Total Ankle Arthroplasty.

Background:The safety of outpatient total ankle arthroplasty (TAA), and factors predictive of early complications are poorly understood. The objective of this study was to determine the frequency of early complications in patients undergoing outpatient TAA compared to a matched inpatient TAA cohort. Factors predictive of early complications following TAA are elucidated.Methods:A retrospective review of prospectively collected data from the 2011-2018 American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database was performed. An unadjusted analysis comparing complication rates in outpatient, and inpatient TAA was performed followed by a propensity score–matched cohort analysis. A multivariate logistic regression model was then used to identify significant independent predictors for complications, reoperation, and readmission following TAA.Results:A total of 1487 patients (198 outpatient, 1289 inpatient) undergoing TAA were included in the study. Inpatient TAA was associated with increased 30-day readmission compared with outpatient TAA (3.54% vs 0.51%, P = .032) in a matched cohort analysis. Thirty-eight (2.6%) patients had a minor complication, with 16 (1.1%) patients having a major complication after TAR. Nineteen (1.3%) patients underwent reoperation, and 42 (2.8%) patients were readmitted within 30 days of the index TAR. Multivariate analysis identified factors predictive of early complications to include length of stay (LOS) >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus.Conclusion:From this relatively limited data set, outpatient TAA appears to be safe for management of end-stage ankle arthritis in select patients. Inpatient status was associated with an increased rate of 30-day readmission following TAA. Postoperative length of stay >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus were identified to be associated with early postoperative complications following TAA in this cohort.Level of EvidenceLevel III, retrospective cohort study.

Nationwide Analysis of Total Ankle Replacement and Ankle Arthrodesis in Medicare Patients: Trends, Complications, and Cost.

Surgical management of end-stage ankle arthritis consists of either ankle arthrodesis (AA) or total ankle replacement (TAR). The purpose of this study was to evaluate utilization trends in TAR and AA and compare cost and complications. Medicare patients with the diagnosis of ankle arthritis were reviewed. Patients undergoing surgical intervention were split into AA and TAR groups, which were evaluated for trends as well as postoperative complications, revision rates, and procedure cost. A total of 673 789 patients were identified with ankle arthritis. A total of 19 120 patients underwent AA and 9059 underwent TAR. While rates of AA remained relatively constant, even decreasing, with 2080 performed in 2005 and 1823 performed in 2014, TAR rates nearly quadrupled. Average cost associated with TAR was $12559.12 compared with $6962.99 for AA (P < .001). Overall complication rates were 24.9% in the AA group with a 16.5% revision rate compared with 15.1% and 11.0%, respectively, in the TAR group (P < .001). Patients younger than 65 years had both higher complication and revision rates. TAR has become an increasingly popular option for the management of end-stage ankle arthritis. In our study, TAR demonstrated both lower revision and complication rates than AA. However, TAR represents a more expensive treatment option. Level III: Retrospective comparative study.

Total Ankle Arthroplasty Survivorship: A Meta-analysis

The gold standard for management of end-stage ankle arthritis was previously ankle arthrodesis; however, improvements in total ankle replacements are making this a more viable treatment option. The primary aim of this meta-analysis was to evaluate the survivorship of total ankle replacement implants currently in use.An extensive search strategy initially captured 20,842 citations that were evaluated for relevance.Abstract screening produced 97 articles to be read in entirety, of which 10 articles studying 1963 implants met all prospective inclusion criteria for analysis.Overall survivorship of all implants was93.0% (95% confidence interval, 85.2-96.9) using a random effect model. There was significant heterogeneity between the studies (Q = 131.504).Meta-regression identified an inverse relationship between survivorship and study follow-up duration (p < .0001).Furthermore, age (p = .36) and implant type (fixed-bearing [95.6%, 95% confidence interval, 85.9-98.7] versus mobile-bearing ]89.4%, 95% confidence interval, 79.6%-94.8%]) did not have a statistically significant impact on survivorship, p = .213.However, patients with higher preoperative functional scores had improved survivorship (p = .001). Complications were inconsistently reported with varied definitions.In order of reported frequency, complications were classified into technical error (28.15%), subsidence (16.89%), implant failure (13.28%), aseptic loosening (6.3%), intraoperative fracture (5.67%), wound problems (4.3%), deep infection (1%), and postoperative fracture (0.0001%).Overall study quality was low, with only 10% being prospective and 90% from nonregistry data.The results from this meta-analysis revealed a promising overall survivorship of current implants in use for total ankle replacement; however higher quality studies with standardized outcomes measures are needed.

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.

Considerations in the Surgical Management of End-Stage Ankle Arthritis: Commentary on an article by Andrea N. Veljkovic, BComm, MPH, MD, FRCSC, et al.: "Outcomes of Total Ankle Replacement, Arthroscopic Ankle Arthrodesis, and Open Ankle Arthrodesis for Isolated Non-Deformed End-Stage Ankle Arthritis".

Considerations in the Surgical Management of End-Stage Ankle Arthritis: Commentary on an article by Andrea N. Veljkovic, BComm, MPH, MD, FRCSC, et al.: "Outcomes of Total Ankle Replacement, Arthroscopic Ankle Arthrodesis, and Open Ankle Arthrodesis for Isolated Non-Deformed End-Stage Ankle Arthritis".

The effect of patient age and diagnosis on the 5-year outcomes of mobile-bearing total ankle replacement

Total Ankle Replacement is an established technique for the management of end-stage ankle arthritis. However, there are few studies focussing on patient-reported outcomes in the medium and long term related to age or arthritis type. We compared demographic data and patient-reported outcomes preoperatively and at five years postoperatively for patients who underwent total ankle replacement with the aim of establishing whether differences exist in outcome depending on patient age or diagnosis. The Foot and Ankle Score (FAOS) and 36-item Short-Form (SF-36) Health Survey were analysed by diagnosis (osteoarthritis, rheumatoid arthritis, post-traumatic arthritis) and age (under or over 60 years).At 5 years, the post-traumatic arthritis group had a significantly higher composite score than the osteoarthritis (p<0.0001) or rheumatoid arthritis groups (p<0.0001). Only the post-traumatic arthritis group experienced a significant increase in composite SF-36 score from baseline (p<0.0001). There was a significant improvement from pre-operatively to 5 years in all three domains of the FAOS and in total scores in both groups (over 60 p<0.0001; 60 and under p=0.0002). There was a significant improvement in composite SF-36 score from pre-operative to 5 years in the patients 60 years or younger at the time of surgery (p=0.0006), but not for the patients over 60. Three patients have been revised (4%), at a mean of 4.8 years following surgery with one patient awaiting revision.

Effect of Type 1 and Type 2 Diabetes Mellitus on Complication and Reoperation Rates of Ankle Arthrodesis and Total Ankle Arthroplasty

Category: Diabetes Introduction/Purpose: Diabetes mellitus (DM) poses a risk for increased rate of complications in many orthopaedic procedures, especially in patients undergoing elective arthroplasty procedures. Treatment of end-stage ankle arthritis includes both arthroplasty and arthrodesis. Current literature provides minimal guidance regarding outcomes of total ankle replacement (TAR) or ankle arthrodesis (AA) in diabetic patients. The authors of this study utilized a large database to compare rates of postoperative complications and reoperations of diabetic patients undergoing surgical management of ankle arthritis to rates seen in non-diabetic patients. Methods: Using the PearlDiver Technologies, Inc. database, Medicare patients diagnosed with ankle arthritis using ICD-9 codes were identified from 2005 to 2014. Patients were then sorted as diabetic or non-diabetic. Diabetic patients were then further stratified into Type 1 diabetes (T1DM) and Type 2 diabetes (T2DM). Type 2 diabetics requiring insulin (T2ID) and not requiring insulin (T2NID) were also isolated. Patients were identified who underwent either AA or TAR utilizing ICD-9 procedure and CPT codes. These groups were evaluated for postoperative complications and reoperation rates. Chi-Squared testing was used to determine significance. Multivariate analysis was performed to determine whether diabetes represents an independent risk factor. Results: 1477 diabetic patients underwent TAR and 5399 underwent AA versus 3900 TAR and 7838 AA in nondiabetics. Diabetics undergoing AA experienced complications at 32.2%, reoperations at 30.8%, and revisions at 18.7% versus 13.3%, 22.3%, and 19.2% respectively in patients without diabetes(P&lt;0.05). In diabetics undergoing TAR, the complication rate was 21.6% and reoperation rates were 16.9% versus 12.5% and 13% respectively in their non-diabetic counterparts(P&lt;0.05). Revision rates were similar. Patients with T1DM had more reoperations and complications in both TAR and AA compared to those with T2DM (P&lt;0.05). In both surgical groups, Patients with T2ID had more complications and reoperations than those with T2NID(P&lt;0.05). Multivariate analysis revealed diabetes as an independent risk factor for complication and reoperation in AA but only complication in TAR(P &lt;0.05). Conclusion: Patients with a diagnosis of diabetes mellitus experienced higher complication and total reoperation rates when undergoing either TAR or AA. T1DM appears to impart a greater risk of surgical complication and repeat surgical intervention than does T2DM. However when insulin is required in T2DM, complication and reoperation rates are similar to those of T1DM. Patient selection for surgical management of end-stage ankle arthritis should incorporate diabetic type and insulin dependency when considering surgical intervention.

Minimum 20 Year Follow-Up of Semi-Constrained Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: With the introduction of newer generations of total ankle arthroplasty (TAA) constructs, the incidence of TAA in the United States has been increasing. While TAA has emerged as an alternative to ankle arthrodesis for the management of end-stage ankle arthritis, long-term data evaluating clinical outcomes and the survivorship of ankle prostheses is lacking. The purpose of this study was to report the clinical outcomes and radiographic survivorship of a second-generation, semi-constrained titanium and cobalt-chromium total ankle prosthesis at minimum twenty-year follow-up in order to provide a benchmark comparison for future generations of TAA design. Methods: 132 total ankle replacements in 126 patients were performed by a single surgeon between July 1984 and October 1994. Follow-up evaluation consisted of determining revision status, completion of the validated ankle osteoarthritis scale, a short questionnaire, and a review of the available radiographs. All radiographs were evaluated for evidence of progressive radiolucent lines, osteolysis and component subsidence. Results: At minimum twenty-year follow-up, 37 patients were alive, 89 were deceased, and 5 were lost to follow-up. For living patients, average clinical follow up was 25.3 years. Average radiographic follow-up was 21.4 years. Over the minimum 20 year follow-up, 29 ankles were revised (23%). For living patients, 13 ankles were revised (35%). Conclusion: Twenty-three percent of all patients and 35% of living patients required a revision over the minimum 20 year follow up interval. 65% of living patients have retained their prosthesis and 75% of the entire cohort are still functioning with their original ankle replacement or died with the original ankle replacement in place. This study should provide a benchmark for newer designs when they obtain this length of follow-up.

Functional and clinical outcomes of total ankle arthroplasty in elderly compared to younger patients.

Total ankle arthroplasty (TAA) is becoming an increasingly utilized procedure for the management of end-stage ankle arthritis. Elderly patients are the fastest growing segment of the population in the western world, creating a unique challenge to the health economics of our era. Determining if elderly patients with end-stage ankle arthritis demonstrate the same improvements in clinical outcomes and functional measures of gait following TAA would be valuable. This can aid to evaluate the utilization of TAA in this enlarging cohort of our population. Consecutive series of twenty-one patients over the age of 70, who underwent TAA for end-stage ankle arthritis, was prospectively compared to a series of twenty-one patients aged 50-60, who underwent the same procedure by single surgeon during same time period. Clinical outcomes were measured with outcome scores including VAS pain score, AOFAS Ankle and Hindfoot Score, and the SF-36. Three-dimensional gait analysis was performed preoperatively and at a minimum of one year postoperatively, to measure temporal-spatial, kinematic, and kinetic parameters of gait. Mixed model multivariate statistical analysis was used to evaluate and compare the independent contributions to outcomes of the surgical intervention over time; of patient age; and of time-plus-age interaction, as these influenced both the clinical outcomes and the functional gait outcomes. Statistically significant improvements in VAS pain scores, AOFAS ankle/hindfoot scores, and SF-36 scores were demonstrated in both age groups. Following surgery, there were improvements in all parameters of gait, including temporal-spatial parameters as step length and walking velocity; kinematic parameters, including, increase in total range of motion to a total of 17-19°; and kinetic parameters, including increase in ankle power and moment. The improvements both in clinical and gait outcomes were equivalent in the two age groups. In this comparative study, it is shown that both elderly patients over the age of 70 and younger patients aged 50-60 demonstrated equivalent improvements clinical and gait outcomes following ankle arthroplasty. This may be important data both for clinical decision-making and the health economics for our ageing population.

Total Ankle Arthroplasty: An Imaging Overview.

With advances in implant technology, total ankle arthroplasty (TAA) has become an increasingly popular alternative to arthrodesis for the management of end-stage ankle arthritis. However, reports in the literature do not focus on the imaging features of TAA. Through a literature review, we demonstrate basic design features of the current ankle arthroplasty system, and the normal and abnormal postoperative imaging features associated with such devices. Pre- and postoperative evaluations of ankle arthroplasty mainly include radiography; in addition, computed tomography and magnetic resonance imaging provide further characterization of imaging abnormalities. Familiarization with multimodal imaging features of frequent procedural complications at various postoperative intervals is important in radiological practice.

Management of End-Stage Ankle Arthritis: Cost-Utility Analysis Using Direct and Indirect Costs.

Total ankle replacement and ankle fusion are costly but clinically effective treatments for ankle arthritis. Prior cost-effectiveness analyses for the management of ankle arthritis have been limited by a lack of consideration of indirect costs and nonoperative management. The purpose of this study was to compare the cost-effectiveness of operative and nonoperative treatments for ankle arthritis with inclusion of direct and indirect costs in the analysis. Markov model analysis was conducted from a health-systems perspective with use of direct costs and from a societal perspective with use of direct and indirect costs. Costs were derived from the 2012 Nationwide Inpatient Sample (NIS) and expressed in 2013 U.S. dollars; effectiveness was expressed in quality-adjusted life years (QALYs). Model transition probabilities were derived from the available literature. The principal outcome measure was the incremental cost-effectiveness ratio (ICER). In the direct-cost analysis for the base case, total ankle replacement was associated with an ICER of $14,500/QALY compared with nonoperative management. When indirect costs were included, total ankle replacement was both more effective and resulted in $5900 and $800 in lifetime cost savings compared with the lifetime costs following nonoperative management and ankle fusion, respectively. At a $100,000/QALY threshold, surgical management of ankle arthritis was preferred for patients younger than ninety-six years and total ankle replacement was increasingly more cost-effective in younger patients. Total ankle replacement, ankle fusion, and nonoperative management were the preferred strategy in 83%, 12%, and 5% of the analyses, respectively; however, our model was sensitive to patient age, the direct costs of total ankle replacement, the failure rate of total ankle replacement, and the probability of arthritis after ankle fusion. Compared with nonoperative treatment for the management of end-stage ankle arthritis, total ankle replacement is preferred over ankle fusion; total ankle replacement is cost-saving when indirect costs are considered and demonstrates increasing cost-effectiveness in younger patients. As indications for and utilization of total ankle replacement increase, continued research is needed to define appropriate subgroups of patients who would likely derive the greatest clinical benefit from that procedure. Economic and decision analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Obesity Is Associated With Increased Complications After Operative Management of End-Stage Ankle Arthritis.

Total ankle arthroplasty (TAA) and ankle arthrodesis (AA) are two operative options for the management of end-stage ankle arthritis that has failed conservative interventions. Obesity is associated with a greater incidence of musculoskeletal disease, particularly osteoarthritis of the weight-bearing joints, including the ankle. The objective of the present study was to use a national database to examine the association between obesity and postoperative complications after TAA and AA. The PearlDiver database was queried for patients undergoing AA and TAA using International Classification of Diseases, 9th Revision (ICD-9) procedure codes. Patients were divided into obese (body mass index ≥30 kg/m(2)) and nonobese (body mass index <30 kg/m(2)) cohorts using ICD-9 codes for body mass index and obesity. Complications within 90 days postoperatively were assessed using ICD-9 and Current Procedural Terminology (CPT) codes. 23,029 patients were identified from 2005 to 2011, including 5361 with TAA and 17,668 with AA. Obese TAA patients had a significantly increased risk of 90-day major, minor, local, systemic, venous thromboembolic, infectious, and medical complications compared with nonobese patients. The incidence of revision TAA was also significantly higher in obese patients compared with nonobese patients. Findings were similar for AA, as all types of complications were significantly higher in obese patients compared with nonobese patients. Obesity was associated with significantly increased rates of all complications after both TAA and AA. The cause of this association was likely multifactorial, including increased rates of medical comorbidities, intraoperative factors, and larger soft tissue envelopes. Level III, comparative series.

Inter- and Intraobserver Reliability of the COFAS End-Stage Ankle Arthritis Classification System

End-stage ankle arthritis should have an appropriate classification to assist surgeons in the management of end-stage ankle arthritis. Outcomes research also requires a classification system to stratify patients appropriately. Six fellowship trained foot and ankle surgeons met on two occasions to derive a classification system for end-stage ankle arthritis. A four-part classification system was designed. Four surgeons reviewed blinded patient profiles and radiographs on two occasions to determine the inter- and intraobserver reliability. Good interobserver reliability (kappa = 0.62) and intraobserver reproducibility (kappa = 0.72) was demonstrated for the classification system. The COFAS classification system appears to be a valid tool for the management and research of end-stage ankle arthritis.

Correction of Varus Talar Deformities in Ankle Joint Replacement

There is limited information on surgical techniques for correcting a varus talar deformity in patients undergoing ankle joint replacement. This article reviews 32 patients with a varus talar deformity of >10°, who underwent a total ankle replacement . Of the 32 ankles, 15 had a varus talar deformity of >15°. The importance of appropriate preoperative assessment and a stepwise intraoperative approach is described in detail. With an average follow-up of 17 months, a satisfactory radiographic correction was obtained in 94% (30/32) of the ankles. It is noted that 75% (24/32) of patients required ancillary procedures after ankle replacement to obtain a plantigrade foot. This review will demonstrate that correction of moderate to severe varus talar deformities is possible when considering a total ankle replacement for the management of end-stage ankle arthritis.