Outpatient Total Ankle Arthroplasty Research Articles

Comparison of Complication Rates and Surgical Costs for Total Ankle Replacements Performed in the Outpatient vs Inpatient Setting

Introduction/Purpose: Increasing data has highlighted the safety and cost-effectiveness of outpatient hip, knee, and shoulder arthroplasty. However, limited evidence – mainly small, single institution case series – has explored complication rates and costs between outpatient and inpatient total ankle arthroplasty (TAA) surgeries. Methods: Utilizing Medicare claims from 2016 to 2019, we retrospectively identified patients ≥65 years of age who underwent TAA based on CPT coding. Patients on Medicare HMO, under age 65, and dual-eligible patients were excluded. Within this dataset, we compared surgeries performed in the outpatient versus inpatient setting. We compared groups based on readmission, all-complication, and infection rates within 1-year of TAA using logistic regressions controlling for age, sex, race, and comorbidity. To help mitigate bias, we also performed a propensity matched model with the same variables. Data were reported as percentage point (PPT) differences (95% CI) between groups, with a positive number indicating higher complication rates and costs among patients treated in the inpatient setting. Results: In total, 8,281 total ankle arthroplasty cases were identified (outpatient: 5,524 and inpatient: 2,757. Compared to inpatient cases, outpatient TAA surgeries were performed on younger, healthier (as assessed by Charlson Comorbidity Index (CCI) scores) patients who were more likely to be female (p < 0.001). In logistic regression analyses, outpatient TAA cases had lower readmission, all-complication, infection, mortality, and device-associated complication rates (p < 0.001) as compared to inpatient surgeries. Further, outpatient surgeries had sizable cost reductions compared to inpatient surgeries (p < 0.001). Conclusion: TAA performed in the outpatient setting appears to have less complications and decreased cost compared to inpatient procedures – though inpatient surgeries were presumably riskier as they were performed on older patients with increased co-morbidities. When clinically appropriate, though, TAA as an outpatient procedure appears to provide substantial reductions in cost with notable reductions in surgical risk.

Safety of Same-Day Discharge Following Total Ankle Arthroplasty: A Retrospective Cohort Analysis.

Joint replacement procedures have traditionally been performed in an inpatient setting to minimize complication rates. There is growing evidence that total ankle arthroplasty (TAA) can safely be performed as an outpatient procedure, with the potential benefits of decreased health care expenses and improved patient satisfaction. Prior studies have not reliably made a distinction between outpatient TAA defined as length of stay <1 day and same-day discharge. The purpose of our study was to compare a large volume of same-day discharge and inpatient TAA for safety and efficacy. Patients undergoing TAA at our US-based institution are part of an institutional review board-approved registry. We queried the registry for TAA performed by the single highest-volume surgeon at our institution between May 2020 and March 2022. Same-day discharge TAA was defined as discharge on the day of the procedure. Patient demographics, baseline clinical variables, concomitant procedures, postoperative complications, and patient-reported outcomes were collected. Postoperative outcomes were compared after 1:1 nearest-neighbor matching by age, sex, Charlson Comorbidity Index (CCI), and American Society of Anesthesiologists (ASA) score. Multivariable models were created for comparison with the matched cohort outcome comparison analysis. Our same-day discharge group was younger (median 58 vs 67 years; P < .001), with proportionally fewer females (36.4% vs 51.4%; P = .044) and lower Charlson Comorbidity Indices (median 1 vs 3; P < .001) than the inpatient group. At a median follow-up of 1 year, after matching by age, sex, CCI, and ASA score, there was no difference in complications (P = .788), reoperations (P = .999), revisions (P = .118), or Patient-Reported Outcomes Measurement Information System (PROMIS) scores between the 2 groups. Multivariable analyses performed demonstrated no evidence of association between undergoing same-day discharge TAA vs inpatient TAA and reoperation, revision, complication, or 1-year PROMIS scores (P > .05). In our system of health care, with appropriate patient selection, same-day discharge following TAA can be a safe alternative to inpatient TAA. Level III, retrospective cohort study.

Outpatient Total Ankle Arthroplasty (TAA) as a Safe and Lower Cost Alternative to Inpatient TAA

Category: Ankle; Other Introduction/Purpose: Joint replacement procedures have traditionally been performed in an inpatient setting to minimize complication rates. While the Centers for Medicare and Medicaid Services (CMS) have made provisions for outpatient total hip and knee arthroplasty, Medicare patients undergoing total ankle arthroplasty (TAA), until recently, required inpatient admission. There is growing evidence that TAA can safely be performed as an outpatient procedure, with the benefit of decreased healthcare expenses and improved patient satisfaction. Studies have largely investigated direct costs associated with TAA. The purpose of our study was to compare payer costs and complication rates between inpatient and outpatient TAA using a large publicly available for-fee database. Methods: The PearlDiver Database was queried to identify TAA-associated claims for all payer types from January 2010 to April 2021. The claims were identified by the following ICD and CPT codes and analyzed based on service location: CPT-27700, CPT- 27702, ICD-9-P-8156, ICD-10-P-0SRF07Z, ICD-10-P-0SRF0JZ, ICD-10-P-0SRF0KZ, ICD-10-P-0SRG07Z, ICD-10-P-0SRG0JZ, ICD-10-P-0SRG07Z. Baseline comparisons of age, Charleston Comorbidity Index (CCI), geographic region, and payer type were performed. Total reimbursement amount for all associated claims was summed and divided by the number of patients assigned to those claims for the average amount paid per patient. Total cost over a 90-day period was calculated by summing the cost of all claims assigned to patients who underwent TAA within this time frame. The data were analyzed for postoperative infections and readmissions within 90 days as well as failure of TAA defined as conversion to ankle arthrodesis, revision ankle arthroplasty, and/or infection requiring postoperative irrigation and debridement. Results: A total of 7,520 patients who underwent outpatient TAA and 10,772 patients who underwent inpatient TAA were identified. The average age was 54.3 years for outpatients and 63.9 years for inpatients (p Conclusion: In patients undergoing TAA, both average paid per patient and total cost within 90 days were significantly lower in the outpatient setting. Patients who underwent TAA in the outpatient setting as compared to the inpatient setting were younger, with a lower comorbidity index and a different distribution by geographic region and payer type. Complication rates including postoperative infections, readmissions, and arthroplasty failures were significantly lower in the outpatient setting, perhaps due to differences in baseline patient characteristics. These data suggest that outpatient TAA is a safe and lower cost alternative to inpatient TAA.

Outpatient Total Ankle Arthroplasty (TAA) as a Rising Alternative to Inpatient TAA: A Database Analysis.

There is growing evidence that total ankle arthroplasty (TAA) can safely be performed as an outpatient procedure, with the benefit of decreased health care expenses and improved patient satisfaction. The purpose of our study was to compare readmissions, arthroplasty failures, infections, and annual trends between outpatient and inpatient TAA using a large publicly available for-fee database. The PearlDiver Database was queried to identify outpatient and inpatient TAA-associated claims for several payer types from January 2010 to October 2021. Preoperative patient characteristics and annual trends were compared for inpatient and outpatient TAA. International Classification of Diseases, Ninth and Tenth Revision, diagnosis codes were used to identify infections and arthroplasty failures. Complications rates were compared after matching patients by age, gender, and the following comorbidities: diabetes, smoking, congestive heart failure (CHF), hypertension (HTN), obesity, and chronic kidney disease (CKD). A total of 12 274 patients were included in the final exact-matched analysis for complications, with 6137 patients in each group. Outpatients had a significantly lower rate of readmission within 90 days (2.6% vs 4.0%, P < .001), arthroplasty failure (4.1% vs 6.9%, P < .001), and infection (2.4% vs 3.1%, P = .015). Among database enrollees, outpatient TAA has risen in proportion to inpatient TAA from 2019 to 2021. Outpatient TAA had lower rates of risk-adjusted readmission, arthroplasty failure, and infection compared to inpatient TAA. Level III, retrospective comparative database study.

The Rise of Total Ankle Arthroplasty Use: A Database Analysis Describing Case Volumes and Incidence Trends in the United States Between 2009 and 2019.

Ankle arthrodesis has been the mainstay treatment for end-stage ankle arthritis. The popularity of total ankle arthroplasty (TAA) has been on the rise due to improved implant design and postoperative outcomes. The purpose of this study was to describe the basic epidemiology and trends of annual procedure volumes and incidence in the general American population as well as in different population subgroups from 2009 to 2019. We hypothesize that the incidence of TAA has significantly risen while the median length of hospital stay has decreased nationwide. The IBM MarketScan database was queried for patients who underwent TAA from January 2009 to December 2019 based on Current Procedural Terminology coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of TAA. Procedural volume and incidence were calculated for annual sums, gender, age subgroups, inpatient and outpatient TAA, as well as in four statistical geographic regions in the United States. Median length of hospital stay was calculated and trended annually for inpatient TAA. A total of 41,060 primary TAAs were identified in the database from 2009 to 2019, in which 52.5% were performed in males. Annual volumes increased by 136.1%, from 2180 to 5147 procedures nationwide. Incidence reported per 100 000 population increased by 120.8%. Both inpatient and outpatient procedures have increased, by 242.5% and 86.6%, respectively. Median length of hospital stay decreased from 3 days in 2009 to 1 day in 2019 and did not differ between genders. Growth in incidence was demonstrated in males and females above the age of 54 years with the largest growth in annual incidence found between 65 and 74 years. Incidence rose in the South and West of the United States by 111.8% and 136.5%, respectively. We found that annual volumes and incidence rates of primary TAA has increased between 2009 and 2019. Although both inpatient and outpatient surgery have become more frequent, inpatient volumes and incidence have increased almost 3 times more than those of outpatient surgery. Length of hospital stay decreased over the study years. When adjusted for the same study period, the cumulative annual growth rates of TAA were found to be 2 times greater than total knee arthroplasty and 3.6 times greater than total hip arthroplasty. Level III, retrospective database review.

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.

Safety and Effectiveness of Outpatient Total Ankle Arthroplasty.

Background:Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA.Methods:This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results.Results:In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA.Conclusions:The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA.Level of Evidence: Level IV, case series.

The Safety Profile of Same-Day Outpatient Total Ankle Arthroplasty

There has been significant change in the health care policy in the United States in recent years with an increasing focus on health care costs and patient satisfaction. One strategy of cost containment is to transition outpatient surgery away from high cost hospital environments. Total ankle arthroplasty has begun the evolution to outpatient settings; however, there is limited published literature on the results of outpatient total ankle arthroplasty (TAA). The purpose of the present study was to review the safety profile of same day outpatient TAA at an ambulatory surgery center. A review of consecutive patients who underwent same day outpatient TAA for end-stage ankle arthritis with a minimum of 12 months' follow-up was performed. The primary outcomes assessed were the incidence of perioperative adverse medical events, hospital admissions related to the procedure, and postoperative complications (minor and major). Univariate analyses were performed. Fifty-one patients who underwent same-day TAA between June 2016 and July 2018 were included; mean follow-up was 20.7 months (± 7.6). The mean age at time of surgery was 56.5 years (± 7.2), with a mean body mass index of 30.4 (± 5.3). Overall, there were no perioperative adverse medical events or hospital admissions related to the procedure. Five minor complications (9.8%) and 7 major (13.7%) were recorded. Of the major complications, only 1 required TAA revision. Implant survivorship during the most recent follow-up was 98%. The present study suggests that TAA can be performed safely in an outpatient ambulatory setting. Additional comparative studies with larger TAA cohorts and patient reported outcomes are warranted.

Total Ankle Arthoplasty as a Day Case Surgery: How Safe and Effective it is?

Category:Ankle ArthritisIntroduction/Purpose:Outpatient total joint arthroplasty (OTJA) allows for a safe, cost effective pathway for appropriately selected patients. Total ankle arthroplasty (TAA) is a surgical procedure commonly used for patients with painful arthritis. As the number of TAA procedures increase, so does the associated economic burden. The purpose of this study was to evaluate patients undergoing total ankle arthroplasty, who were discharged on the same day as undergoing surgery. These patients have stayed in the hospital for <12 hours, and are referred to as ‘‘outpatients.’’ Outpatients were evaluated with regard to the following outcomes: (1) postoperative pain; (2) perioperative complications and healthcare provider visits (readmission). We also assessed patients’ satisfaction regarding discharge on the same day as surgery.Methods:The medical records of 46 consecutive TAA outpatients from July 2018 to June 2019 with a minimum 1 month post- operative follow-up, were reviewed. All patients received an Integra Cadence TAA. Prior to surgery, all patients received popliteal blocks. Patients were discharged home with a popliteal catheter, which they were to remove themselves after 48 hours. After removal of the catheter, patients were prescribed oral pain medication to help with any pain or discomfort. The following data was collected: demographics, comorbidities, (ASA) class, and perioperative complications, including wound breakdown, infection, revision and non-revision surgeries. At their 1-month post-operative visit, patients completed a questionnaire regarding their satisfaction post-surgery, which consisted of six questions.Results:There were no readmissions for pain control, no signs of wound infection among the 46 outpatients. All patients were ‘very satisfied’ with the surgical procedure and with recommend methods of pain control. The majority of patients were also very satisfied with discharge on the same day as surgery with the exception of patients who would have liked to stay overnight. When asked if they would recommend the care they experienced to a friend with the same condition, 46 patients said that they would definitely recommend this process to a friend. In terms of rating their pain on a scale of 0-10 (0 being no pain, 10 being worst pain imaginable), the average score for the 46 patients was 2.03.Conclusion:Our study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory outpatient experience and no readmissions for pain control.

Complication Rates Following Total Ankle Arthroplasty in Inpatient versus Outpatient Populations: A Systematic Review & Meta-Analysis

Total ankle arthroplasty (TAA) is used as an alternative to ankle arthrodesis for adults with severe ankle arthritis. Numerous orthopedic centers have entered the healthcare market offering fast-tracked joint replacement protocols, meanwhile, TAA has been excluded from these joint centers, and is primarily performed in the inpatient setting. The purpose of this study is to examine short-term complications in the inpatient and outpatient settings following TAA using a systematic review and quantitative analysis. We considered all studies examining short-term complications following TAA performed in the inpatient versus outpatient setting occuring within 1 year of the index operation. We summarized data using a pooled relative risk and random effects model. A pooled sensitivity analysis was performed for studies with data on complication rates for inpatient or outpatient populations, which did not have a control group. The quality of included studies was assessed using the Cochrane risk of bias tool. Nine studies were included in the quantitative analysis, with 4 studies in the final meta-analysis. Subjects undergoing inpatient surgery experienced a 5-times higher risk of short-term complications compared to the outpatient group (risk ratio 5.27, 95% confidence interval 3.31, 8.42). Results did not change after sensitivity analysis (inpatient weighted mean complication rate: 9.62% vs outpatient weighted mean 5.02%, p value <.001). The overall level of evidence of included studies was level III, with a moderate to high risk of bias. Outpatient TAAs do not appear to pose excess complication risks compared to inpatient procedures, and may therefore be a reasonable addition to experienced centers that have established a fast-track outpatient total joint protocol.

A propensity score-matched analysis comparing outpatient and short-stay hospitalization to standard inpatient hospitalization following total ankle arthroplasty

BackgroundGiven the trend toward value-based care, there has been increased interest in minimizing hospital length of stay (LOS) after orthopedic procedures. Outpatient total ankle arthroplasty (TAA) has become more popular in recent years; however, research on surgical outcomes of this procedure has been limited. This study sought to employ large sample, propensity score-matched analyses to assess the safety of outpatient and short-stay discharge pathways following TAA.MethodsThe ACS NSQIP database was used to identify 1141 patients who underwent primary and revision TAA between 2007 and 2017. Propensity score matching was used to match patients based on several factors, including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and several comorbidities. The incidence of various 30-day complications was compared between the short and standard LOS groups to assess for any differences in short-term outcomes.ResultsA total of 892 patients were included in the final propensity score-matched analysis, with 446 patients in each group. The short LOS group had a significantly lower rate of medical complications (0.2% vs. 2.5%, p = 0.006) and non-home discharge (1.3% vs. 12.1%, p < 0.001). There was no significant difference in operative complications (0.4% vs. 1.8%, p = 0.107), unplanned readmission (0.4% vs. 1.1%, p = 0.451), reoperation (0.2% vs. 0.4%, p > 0.999), return to the OR (0.2% vs. 0.9%, p = 0.374), or mortality (0.7% vs. 0.0%, p > 0.249) between the short and standard LOS groups.ConclusionsOutpatient and short-stay hospitalization had comparable safety to standard inpatient hospitalization after TAA. Outpatient or short-stay TAA should be considered for patients with low risk of short-term complications.

Comparative Analysis of Short-Term Postoperative Complications in Outpatient Versus Inpatient Total Ankle Arthroplasty: A Database Study

Ankle arthritis is a potentially debilitating disease, with approximately 50,000 cases diagnosed annually. One treatment option for these patients is total ankle arthroplasty (TAA). This procedure has historically been performed in the inpatient setting with a 1–2-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore it is important to evaluate the safety of specific procedures in the outpatient setting compared with the inpatient setting. This study evaluated the complication rates in inpatient versus outpatient TAA. It analyzed data from the National Surgical Quality Improvement Program for 591 patients who received TAA. Postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. Unadjusted direct comparisons of the cohorts revealed higher complication rates in the inpatient cohort. Inpatients had higher rates of superficial surgical site infections, deep surgical site infections, number of organ/space surgical site infections, pneumonia occurrences, and return to the operating room, but these differences were not significant. These results showed no significant increase in complication rates in outpatients compared to inpatients. Our results suggest that inpatient and outpatient TAA show similar complication rates. This suggests that outpatient TAA is safe and may be a superior option for certain populations. Further investigation is warranted to verify these conclusions.

A Comparative Analysis of Short Term Postoperative Complications in Outpatient vs. Inpatient Total Ankle Arthroplasty

Category: Ankle Introduction/Purpose: Ankle arthritis is a potentially debilitating disease with approximately 50,000 cases diagnosed annually. Once conservative management fails, surgical options for these patients include total ankle arthroplasty (TAA) and ankle arthrodesis. Younger, more active patients may prefer TAA as it may allow better ankle mobility compared to ankle arthrodesis. TAA has historically been performed in the inpatient setting with a one- to two-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore, it is important to evaluate the safety of specific procedures in the outpatient setting compared to the inpatient setting. This study evaluates the complication rates in inpatient vs. outpatient TAA. Methods: Our team conducted a retrospective analysis of data from 591 patients receiving inpatient and outpatient TAA from the NSQIP database. This database contains de-identified patient data and allows retrospective analyses to be performed based on data they have extracted from over 400 hospitals. Demographic information was recorded including age, sex, weight, height, and race. Thirty-day postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. The inpatient and outpatient groups were compared using chi-squared tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Results: 591 total patients were identified that underwent TAA. 66 patients (11.1%) were treated as outpatients and 525 (88.8%) as inpatients. Inpatient TAA had a significantly higher mean operation time (161 min vs 148 min) and a significant difference in length of total hospital stay (2.3 days vs 1.1 days). Inpatients had higher rates of superficial incisional surgical site infection (SSI) (0.57% vs 0%), deep SSI (0.19 % vs 0%), organ/space SSI (0.19% vs 0%), pneumonia (0.38% vs 0%), and return to the operating room (0.76% to 0%). However, no significant differences were found in complication rates between inpatient and outpatient groups. There were no occurrences of acute renal failure, wound disruption, pulmonary embolism, stroke, or DVT/thrombophlebitis for inpatients or outpatients. Conclusion: We found no significant difference between inpatient vs. outpatient TAA. Incidental differences we found were that inpatients were significantly more likely to be older in age, diagnosed with diabetes, and inpatients had longer operative times. Our results suggest that inpatients are more likely, but not significantly, to have a higher occurrence of complications and return to the OR. Therefore, this study suggests that outpatient TAA is safe and may be a superior option for the correct patient population. Further investigation is warranted to verify these conclusions.

A Review of Perioperative Complications of Outpatient Total Ankle Arthroplasty.

Total ankle arthroplasty (TAA) is commonly pursued for patients with painful arthritis. Outpatient TAA are increasingly common and have been shown to decrease costs compared to inpatient surgery. However, there are very few studies examining the safety of outpatient TAA. In this study, we retrospectively reviewed 65 consecutive patients who received outpatient TAA to identify complication rates. The medical records of 65 consecutive outpatient TAA from October 2012 to May 2016 with a minimum 6-month follow-up were reviewed. All patients received popliteal and saphenous blocks prior to surgery and were managed with oral pain medication postoperatively. All received a STAR total ankle. Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and perioperative complications including wound breakdown, infection, revision, and nonrevision surgeries were observed. Mean follow-up was 16.6 ± 9.1 months (range, 6-42 months). There were no readmissions for pain control and 1 patient had a wound infection. The overall complication rate was 15.4%. One ankle (1.5%) had a wound breakdown requiring debridement and flap coverage. This patient thrombosed a popliteal artery stent 1 month postop. The 1 ankle (1.5%) with a wound infection occurred in a patient with diabetes, obesity, hypertension, and rheumatoid arthritis. This study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory experience with no readmissions for pain control and 1 wound infection. The 1 wound breakdown complication (1.5%) was attributed to arterial occlusion and not outpatient management. Level IV, retrospective case series.

Perioperative Complications of Outpatient Total Ankle Arthroplasty

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) is commonly pursued for patients with painful arthritis. As the number of TAA increases, so too will the associated economic burden. In the current healthcare environment, savings are in the national spotlight. Studies of total joint arthroplasty (THA and TKA) have demonstrated that outpatient surgery decreases surgical costs.1,2 Additionally, outpatient THA and TKA have not been associated with increased complication or readmission rates.3–6 Outpatient TAA are becoming more common which may lead to decreased costs of care. Despite the potential savings, TAA remains an “inpatient-only procedure” for Medicare patients. Currently, there are no clinical studies examining the safety of outpatient TAA. In this study, we retrospectively reviewed 65 consecutive outpatient TAA to identify complication rates and patient risk factors. Methods: The medical records of 65 consecutive outpatient TAA from October 2012 to May 2016 with a minimum of 6-month follow-up were reviewed. All patients received popliteal and saphenous blocks with bupivacaine and epinephrine prior to surgery and were managed with oral NSAID and narcotic pain medication post-operatively. All patients received a STAR total ankle prosthesis. Demographics, comorbidities, ASA and perioperative complications including wound breakdown, infection, revision and non-revision surgeries were compared to historic controls. Mean follow up was 16.6 +/- 9.1 months (range, 6-42 months). Results: The overall complication rate in this series was 21.8%. One ankle (1.5%) had a wound breakdown requiring debridement and flap coverage. This patient had a history of Polycythemia Vera with re-thrombosis of their popliteal artery one month after TAA surgery. Two ankles (3%) had deep infections. Nine ankles (13.8%) required non-revision surgery. Three ankles (4.6%) required posterior capsular release, one ankle (1.5%) required medial malleolar screws for symptomatic stress reaction, and three ankles (4.6%) required arthroscopic or open gutter release. Two ankles (3%) required revision surgery. One for talar component subsidence in a patient with Charcot-Marie-Tooth managed with an arthrodesis at eleven months. The other revision was performed for aseptic tibial component loosening and managed with conversion to an INBONE prosthesis at seven months. Conclusion: This study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory outpatient experience and zero patients required readmission for pain control. The one wound complication (1.5%) was attributed to arterial occlusion and not outpatient management. This compares to the 6.6-28% wound breakdown rate found in the literature.7–10 Our revision surgery rate (3%) was comparable to the 3.1-16.5% rate found in the literature, and was also not attributed to outpatient management.7–10 We feel this demonstrates that outpatient TAA can be performed safely.

Outpatient Total Ankle Arthroplasty is a Safe Alternative to Traditional Inpatient Admission or Overnight Observation

Category: Ankle, Ankle Arthritis Introduction/Purpose: Safe and cost-effective health care has become a priority in the United States. Total joint surgeons have successfully performed hip, knee, and shoulder arthroplasty procedures in the outpatient setting without compromising safety, satisfaction, or results. The purpose of this study was to evaluate outpatient total ankle arthroplasty (TAA) compared with overnight or more extended hospital stay, with regard to 90-day global period medical and surgical complications, reoperations, readmissions or emergency room visits, and pain control. Methods: The medical records of patients who underwent TAA over a three-and-a-half-year period with a single, fellowship- trained orthopedic foot and ankle surgeon were retrospectively reviewed. Outcome measures included surgical complications, adverse medical events, readmission or emergency room visit for any reason, reoperation within the first 90 days following surgery, any notation of phone call or email to the surgeon’s office prior to first-operative visit regarding pain or other issues, Visual Analog Scale (VAS) pain score at the first post-operative visit, and need for narcotic refill. Outcomes were assessed by admission status; outpatient (discharge home the same day), overnight observation, or inpatient admission (hospital stay of two or more nights). Standard statistical analysis was used and p &lt; 0.05 was considered significant. Results: 82 patients underwent TAA who met inclusion criteria. No statistical differences were found between outpatient, overnight observation, and inpatient admission groups with regard to age, preoperative American Society of Anesthesiologists (ASA) score, gender, laterality, operative indication, or additional number of procedures. A significant difference in complication rate was seen between the three groups (p=0.02), but not rate of readmission or reoperation. Five of sixteen patients (31.2%) admitted for two or more nights following surgery had a complication after discharge versus four of sixty-six (6.1%) in those who were outpatient or admitted overnight (p=0.01). There were no differences in frequency of post-operative phone calls, narcotic refills, or VAS pain score at the first post-operative visit. There were no adverse medical events in any group. Conclusion: With appropriate patient selection and proper instruction, TAA may be performed safely in the outpatient setting. Patients who were discharged home the day of surgery did not require more attention or care in the immediate post-operative period and adverse medical events did not occur. The inpatient group was more likely to have complications, but these mostly consisted of minor superficial wound problems, which may be attributed to patient factors unaccounted for in this study. As health care policy continues to evolve, efficient and cost-effective practices will be a priority and should be further studied.

Safety of Outpatient Total Ankle Arthroplasty vs Traditional Inpatient Admission or Overnight Observation.

Total joint surgeons have successfully performed hip, knee, and shoulder arthroplasty procedures in the outpatient setting without compromising safety, satisfaction, or results. The purpose of this study was to evaluate outpatient total ankle arthroplasty (TAA) as compared with overnight or extended inpatient stay, with regard to 90-day medical and operative complications, reoperations, readmissions or emergency room visits, and pain control. The medical records of patients who underwent TAA with 1 fellowship-trained orthopedic foot and ankle surgeon were reviewed. Outcome measures included operative complications, adverse medical events, readmission or emergency room visit for any reason, or reoperation within 90 days following surgery; surgeon's office contact before first postoperative visit regarding pain or other issues; visual analog scale pain score at the first postoperative visit; and need for narcotic refill. Outcomes were assessed by admission status: outpatient, overnight observation, or inpatient admission. Standard statistical analysis was used, and P < .05 was considered significant. Eighty-one patients underwent TAA who met inclusion criteria, and 8 had a complication (10%). A significant difference in complication rate was seen among groups ( P = .01) but not rate of readmission or reoperation. Of 16 patients, 5 (31%) who were admitted for 2 or more nights following surgery had a complication, as opposed to 3 of 65 (5%) who were outpatient or admitted overnight ( P = .01). There were no differences in frequency of postoperative phone calls, narcotic refills, or visual analog scale pain scores at the first postoperative visit. There were no adverse medical events. With proper instruction, TAA was performed safely in the outpatient setting. As health care policy continues to evolve in the United States, safe and efficient practices will remain a priority. Level III, retrospective comparative study.

Economic Analysis and Patient Satisfaction Associated With Outpatient Total Ankle Arthroplasty.

Total ankle arthroplasty (TAA) is a rapidly growing treatment for end-stage ankle arthritis that is generally performed as an inpatient procedure. The feasibility of outpatient total ankle arthroplasty (OTAA) has not been reported in the literature. We sought to establish proof of concept for OTAA by comparing outpatient vs inpatient perioperative complications, postoperative emergency department (ED) visits, readmissions, patient satisfaction, and cost analysis. From July 2010 to September 2015, a total of 36 patients underwent TAA. Patients with prior ankle replacement, prior ankle infections, neuroarthropathy, or osteonecrosis of the talus were excluded from the study. All patient demographics, tourniquet times, estimated blood loss, comorbidities, concomitant procedures, complications, return ED visits, and readmissions were recorded. Patient satisfaction questionnaires were collected. Twenty-one patients had outpatient surgery and 15 had inpatient surgery. The cohorts were matched demographically. The average length of stay for the inpatient group was 2.5 days. The overall cost differential between the groups was 13.4%, with the outpatient group being less costly. This correlates to a cost savings of nearly $2500 per case. One patient in the outpatient group had a return ED visit on postoperative day 1 for urinary retention. There were no 30-day readmissions in either group. Seventy-one percent of the outpatient group and 93% of the inpatient group would not change to a different postoperative admission status if they were to have the procedure again. Our results show that OTAA was a cost-effective and safe alternative with low complication rates and high patient satisfaction. With proper patient selection, OTAA was beneficial to both the patient and the health care system by driving down total cost. It has the capacity to generate substantial savings while providing equal or better value to the patient. Level III, retrospective comparative study.