Total Ankle Replacement Group Research Articles

Cost-Utility Analysis of Total Ankle Replacement Compared with Ankle Arthrodesis for Patients Aged 50-85 Years with End-Stage Ankle Osteoarthritis: The TARVA Study.

Patients with end-stage ankle osteoarthritis suffer from reduced mobility and quality of life and the main surgical treatments are total ankle replacement (TAR) and ankle fusion (AF). Our aim was to calculate the mean incremental cost per quality-adjusted life-year (QALY) of TAR compared with AF in patients with end-stage ankle osteoarthritis, over 52 weeks and over the patients' lifetime. We conducted a cost-utility analysis of 282 participants from 17 UK centres recruited to a randomised controlled trial (TARVA). QALYs were calculated using index values from EQ-5D-5L. Resource use information was collected from case report forms and self-completed questionnaires. Primary analysis was within-trial analysis from the National Health Service (NHS) and Personal Social Services (PSS) perspective, while secondary analyses were within-trial analysis from wider perspective and long-term economic modelling. Adjustments were made for baseline resource use and index values. Total cost at 52 weeks was higher in the TAR group compared with the AF group, from the NHS and PSS perspective (mean adjusted difference £2539, 95% confidence interval [CI] £1142, £3897). The difference became very small from the wider perspective (£155, 95% CI - £1947, £2331). There was no significant difference between TAR and AF in terms of QALYs (mean adjusted difference 0.02, 95% CI - 0.015, 0.05) at 52 weeks post-operation. The incremental cost-effectiveness ratio (ICER) was £131,999 per QALY gained 52 weeks post-operation. Long-term economic modelling resulted in an ICER of £4200 per QALY gained, and there is a 69% probability of TAR being cost effective at a cost-effectiveness threshold of £20,000 per QALY gained. TAR does not appear to be cost effective over AF 52 weeks post-operation. A decision model suggests that TAR can be cost effective over the patients' lifetime but there is a need for longer-term prospectively collected data. Clinical trial registration ISRCTN60672307 and ClinicalTrials.gov NCT02128555.

Total ankle replacement versus ankle fusion for end-stage ankle arthritis: A meta-analysis.

This study aims to systematically review the efficacy and safety of total ankle replacement (TAR) and ankle fusion (AF) as treatment options for end-stage ankle arthritis. A comprehensive literature search was conducted on data from multiple databases, including PubMed, The Cochrane Library, Construction and Building Materials, Embase, Web of Science, and Scopus for RCTs and prospective cohort studies comparing TAR and AF in patients with end-stage ankle arthritis from inception up to June, 2023. Our primary outcomes of interest included patients' clinical function scores and complications. We employed Review Manager 5.4 and Stata/MP 14.0 software for the meta-analysis. Our analysis incorporated 13 comparative studies, including 11 prospective studies, one pilot RCT, and one RCT. The pooled results revealed no significant difference in postoperative Short Form-36 scores between the TAR and AF groups (MD = -1.19, 95% CI: -3.89 to 1.50, p = .39). However, the postoperative Foot and Ankle Ability Measure scores in the AF group were significantly higher than in the TAR group (MD = 8.30, 95% CI: 1.01-15.60, p = .03). There was no significant difference in postoperative complication rates between the TAR and AF groups (RR = 0.95, 95% CI: 0.59 to 1.54, p = .85). Currently available evidence suggests no significant disparity in postoperative outcomes between TAR and AF. In the short term, TAR demonstrates better clinical scores than AF and lower complication rates. Conversely, in the long term, AF exhibits superior clinical scores and lower complication rates, although this difference is not statistically significant.

Subtalar Joint Fusion For STJ OA before vs after Total Ankle Replacement: Does it affect patient outcomes? – A 10 year follow up clinical study

Category: Ankle; Hindfoot Introduction/Purpose: There is paucity of literature reporting outcomes in patients who undergo subtalar joint fusion surgery before vs. after having a Total Ankle Replacement (TAR). We aimed to study the PROMs in patients who underwent a staged approach of Subtalar arthrodesis (STJA) followed by TAR vs patients who underwent TAR followed by further STJA surgery. Methods: All patients who underwent a STJA surgery and TAR surgery (in either order) between 2006 and 2010 included in this study. patient reported outcomes including WOMAC (Western Ontario McMasters Osteoarthritis score), SF-36 general health score and patient satisfaction scores were compared between groups. They analysed pre-operatively and at 1, 2, 5 and 10 years post-operatively. Out of 210 TARs performed, 14 patients underwent a two staged procedure between 2006 and 2010 by a single surgeon. 5 patients had STJ fusion after TAR (Group A) and 9 patients had STJ fusion before TAR (Group B). Results: Mean age of Group A and B was 52.5 years and 62.1 years respectively. 1 patient in Group A and 3 patients in Group B were deceased. Both groups reported improvement in scores for WOMAC, SF -36 from pre-op to 1 year post operatively (p < 0.05) and the results plateaued to 5 years with slight decline in scores from 5 to 10 years. At 2 years, Group B reported lower scores for stiffness (9.6±11.7 vs. 64.3 ±27.4) p=0.002, At 5 years, Group A reported lower scores than group B for General health and mental health components of SF-36 scores (p=0.044); however, there was no differences between groups for WOMAC, SF-36 and patient satisfaction outcomes at 10 years post-operatively. Conclusion: There were similar outcomes reported by patients who underwent STJA either before or after TAR at average of 10 year follow up in this series

Reliability and validity of the Forgotten Joint Score-12 for total ankle replacement and ankle arthrodesis.

This study evaluated the reliability and validity of the Forgotten Joint Score-12 (FJS-12)-a measure of patients' ability to forget their joints in daily life-in patients who underwent total ankle replacement (TAR) or ankle arthrodesis (AA). Patients who underwent TAR or AA were recruited from seven hospitals. The patients completed the Japanese version of FJS-12 twice, at an interval of two weeks, at a minimum of one year postoperatively. Additionally, they answered the Self-Administered Foot Evaluation Questionnaire and EuroQoL 5-Dimension 5-Level as comparators. The construct validity, internal consistency, test-retest reliability, measurement error, and floor and ceiling effects were evaluated. A total of 115 patients (median age, 72 years), comprising 50 and 65 patients in the TAR and AA groups respectively, were evaluated. The mean FJS-12 scores were 65 and 58 for the TAR and AA groups, respectively, with no significant difference between groups (P = 0.20). Correlations between the FJS-12 and Self-Administered Foot Evaluation Questionnaire subscale scores were good to moderate. The correlation coefficient ranged from 0.39 to 0.71 and 0.55 to 0.79 in the TAR and AA groups, respectively. The correlation between the FJS-12 and EuroQoL 5-Dimension 5-Level scores was poor in both groups. The internal consistency was adequate, with Cronbach's α greater than 0.9 in both groups. The intraclass correlation coefficients of test-retest reliability was 0.77 and 0.98 in the TAR and AA groups, respectively. The 95% minimal detectable change values were 18.0 and 7.2 points in the TAR and AA groups, respectively. No floor or ceiling effect was observed in either group. The Japanese version of FJS-12 is a valid and reliable questionnaire for measuring joint awareness in patients with TAR or AA. The FJS-12 can be a useful tool for the postoperative assessment of patients with end-stage ankle arthritis.

A comparative study of modern total ankle replacement and ankle arthrodesis for ankle osteoarthritis at different follow-up times: a systematic review and meta-analysis.

Total ankle replacement (TAR) or ankle arthrodesis (AA) is the main surgical treatment for end-stage ankle osteoarthritis. However, the therapeutic effect of the two surgical procedures at different follow-up times remains controversial. The purpose of this meta-analysis is to compare the short-term, medium-term, and long-term safety and efficiency of the two modern surgical treatments. We conducted a comprehensive search in PubMed, EMBASE, Cochrane library databases, Web of Science, and Scopus. The main results were the patient's reported outcome measure (PROM) score, satisfaction, complications, reoperation, and surgery success rate. Different follow-up times and implant designs were used to evaluate the source of heterogeneity. We used a fixed effects model for meta-analysis and I2 statistic for evaluating heterogeneity. Thirty-seven comparative studies were included. In the short term, TAR significantly improved clinical scores (AOFAS score: WMD = 7.07, 95% Cl: 0.41-13.74, I2 = 0.0%; SF-36 PCS score: WMD = 2.40, 95% Cl: 2.22-2.58, I2 = 0.0%; SF-36 MCS score: WMD = 0.40, 95% Cl: 0.22-0.57, I2 = 0.0%; VAS for pain: WMD = - 0.50, 95% Cl: - 0.56-0.44, I2 = 44.3%) and had the lower incidence of revision (RR = 0.43, 95% CI: 0.23-0.81, I2 = 0.0%) and complications (RR = 0.67, 95% Cl: 0.50-0.90, I2 = 0.0%). In the medium term, there were still higher improvements in both the clinical scores (SF-36 PCS score: WMD = 1.57, 95% Cl: 1.36-1.78, I2 = 20.9%; SF-36 MCS score: WMD = 0.81, 95% Cl: 0.63-0.99, I2 = 48.8%) and the patient satisfaction (RR = 1.24, 95% Cl: 1.08-1.41, I2 = 12.1%) in the TAR group, but its total complications rate (RR = 1.84, 95% Cl: 1.26-2.68, I2 = 14.9%) and revision rate (RR = 1.58, 95% CI: 1.17-2.14, I2 = 84.6%) were significantly higher than that of the AA group. In the long term, there was no significant difference in clinical score and satisfaction, and a higher incidence of revision (RR = 2.32, 95% Cl: 1.70-3.16, I2 = 0.0%) and complications (RR = 3.18, 95% Cl: 1.69-5.99, I2 = 0.0%) was observed in TAR than in AA. The result of the third-generation design subgroup was consistent with that of the above pooled results. TAR had advantages over AA in the short term due to better performance in terms of PROMs, complications, and reoperation rates, but its complications become a disadvantage in the medium term. In the long term, AA seems to be favored because of lower complications and revision rates, although there is no difference in clinical scores.

2022 Roger A. Mann Award Winner: Total Ankle Replacement vs Arthrodesis (TARVA) Randomized Controlled Trial: 2 Year Results

Category: Ankle Arthritis; Ankle; Hindfoot; Other Introduction/Purpose: End-stage ankle osteoarthritis (EOA) causes severe pain and chronic disability. Once non operative measures have been exhausted the two main surgical treatments include total ankle replacement (TAR) and ankle fusion (AF). Systematic reviews have confirmed that both procedures are effective but there has never been a robust randomised multicentre level I study comparing the two treatments. Our objective was to investigate and compare the clinical and cost effectiveness of TAR against AF in the treatment of end-stage ankle osteoarthritis in patients aged 50-85 years. Methods: TARVA is a multi-centre, parallel-group, open label randomised trial. Patients with EOA, aged 50-85, suitable for either procedure were recruited at 17 UK hospitals. Randomisation was carried out using a secure on-line service and was stratified by surgeon and the presence or absence of adjacent joint OA (based on an independently reviewed preoperative MRI scan). Participants were randomised 1:1 to either TAR or ankle arthrodesis. The primary outcome was the change in the Manchester Oxford Foot & Ankle Questionnaire (MOXFQ) walking/standing domain scores between pre-operation and 52 weeks post- operation. Secondary outcomes measures included FAAM; FAAM (ADL); and Sport subscale scores. Quality of life was measured using the EQ-5D-5L. Total range of tibia to floor motion was measured using a validated method. Health economic analysis used mean incremental cost per quality-adjusted life years (QALY) gained. Analysis was by intention to treat. The trial registration is ISRCTN60672307. Results: Of 933 eligible patients 303 were randomised. 282 underwent surgery. Mean age 68 (71% male). Aetiology was post- trauma in 55.3%, and inflammatory in 7.1%. Groups were well balanced at baseline on all parameters. 54% TARs were fixed bearing. 61% of fusions were performed arthroscopically. At 2 years the adjusted mean difference in the change in MOXFQ W/S between TAR & AF was -4.4(95% CI -11.38 to 2.68, p=0∙23). Post hoc analysis of the commonest implant type (fixed bearing TAR) did show a statistically significant improvement over AF (p=0∙04, -8.9, 95% CI -17.2 to -0.6). Secondary outcomes, EQ5D-VAS and FAAM were significant. Complications included wound healing issues (13.8% vs 5.5%); nerve injuries (4.3% vs 0.7%). 11.8% of AF patients had plain radiographic evidence of non-union but only 6.9% had symptoms. Reoperation rate was 7.2% for TAR vs 5.2% for AF; and revision rate was 0.7% for TAR vs 2.8% for AF. Conclusion: Patients improved in all outcomes in both arms. We did not show a significant difference in our primary outcome measure between TAR and AF overall(p=0.23), but did show significance when fixed bearing TAR alone was compared against AF(p=0.04). Secondary outcomes did show significance. Adjacent joint arthritis increases the size of effect noted between arms. There were more wound healing issues and nerve injuries in TAR group. The symptomatic non-union rate for AF is 6.9%. TAR is likely to be cost-effective compared to AF at the NICE cost-effectiveness threshold of £20,000 per Quality Adjusted Life Year gained over the patients' lifetime.

Cadaveric Gait Simulation of the Effect of Subtalar Arthrodesis on Total Ankle Replacement Kinematics.

Patients undergoing total ankle replacement (TAR) often have symptomatic adjacent joint arthritis and deformity. Subtalar arthrodesis can effectively address a degenerative and/or malaligned hindfoot, but there is concern that it places abnormal stresses on the TAR and adjacent joints of the foot, potentially leading to early TAR failure. This study hypothesized that ankle and talonavicular joint kinematics would be altered after subtalar arthrodesis in the setting of TAR. Thirteen mid-tibia cadaveric specimens with neutral alignment were tested in a robotic gait simulator. To simulate gait, each specimen was secured to a static mounting fixture about a 6-degree of freedom robotic platform, and a force plate moves relative to the stationary specimen based on standardized gait parameters. Specimens were tested sequentially in TAR and TAR with subtalar arthrodesis (TAR-STfuse). Kinematics and range of motion of the ankle and talonavicular joint were compared between TAR and TAR-STfuse. There were significant differences in kinematics and range of motion between TAR and TAR-STfuse groups. At the ankle joint, TAR-STfuse had less internal rotation in early-mid stance (P < .05), with decreased range of motion in the sagittal (-2.7 degrees, P = .008) and axial (-1.8 degrees, P = .002) planes in early stance, and increased range of motion in the coronal plane in middle (+1.2 degrees, P < .001) and late (+2.5 degrees, P = .012) stance. At the talonavicular joint, there were significant differences in axial and coronal kinematics in early and late stance (P < .05). Subtalar arthrodesis resulted in significantly decreased talonavicular range of motion in all planes in early and late stance (P < .003). In ankles implanted with the TAR design used in this study, kinematics of the ankle and talonavicular joint were found to be altered after subtalar arthrodesis. Aberrant motion may reflect altered contact mechanics at the prosthesis and increased stress at the bone-implant interface, and affect the progression of adjacent joint arthritis in the talonavicular joint. These findings may provide a correlate to clinical studies that have cited hindfoot arthrodesis as a risk factor for TAR failure.

10 Year Outcomes of Unilateral vs Bilateral (Staged) Total Ankle Replacement

Category:Ankle Arthritis; AnkleIntroduction/Purpose:Comprehensive long-term outcomes of total ankle replacement (TAR) help guide clinicians when they are deciding on the management of patients with more than single joint arthritis. Some patients will only require unilateral TARs, while others will need bilateral TARs. When deciding on treatment plans for patients, it is important to know the long-term surgical outcomes of both of these groups before treatment can be recommended. Currently there is a paucity of literature on long-term outcomes of unilateral versus bilateral TARs. The aim of the study is to assess long-term outcomes in patients who underwent unilateral vs. staged bilateral TARs.Methods:We performed a retrospective review of a prospectively completed hospital registry database for TAR. This consisted of a consecutive series of TARs performed by one senior surgeon from 2006 to December 2010 with 10-years of follow up. Clinical complications, radiological complications (lucency, cysts, and osteolysis), and patient reported outcome measures (WOMAC score, SF-36, general health survey, and patient satisfaction survey) were included for all patients. Outcomes were evaluated pre-operatively and at 1, 3, 5, and 10 years post-operatively. Three component mobile bearing implants were used in all patients.Results:There were 132 unilateral TARs (Group A) vs. 24 staged bilateral TARs (Group B). WOMAC scores significantly improved from pre-op to 1 year for pain (45.3 to 77.8; 52 to 76) function (49.1 to 77.8; 53.6 to 76) and stiffness (39.8 to 67.9; 55 to 65) in both groups respectively (p<0.05). At 5 years, Group B reported higher function scores than Group A (79.1 vs. 65.7; p=0.05). At 10 years Group B reported significantly better stiffness scores than Group A (78.5 vs. 59.5; p=0.034). There was no significant difference in SF-36 scores between groups at 5 and 10 years. Group A was 40% dissatisfied with return to recreational activities compared to 30% in Group B (p>0.05). Group A reported 16% dissatisfaction with surgery compared to 10% in Group B (p>0.05). At 5 years there were a higher number of radiological and clinical complications in Group A compared to Group B.Conclusion:For patient reported outcomes, staged bilateral TAR patients had more improvement in function at 5 years, and stiffness at 10 years, when compared to unilateral TAR patients. Unilateral TAR patients had higher rates of complications compared to staged bilateral TAR patients at 5 years.A limitation of this study was the smaller size of Group B patients compared to Group A. We will be able to present a detailed breakdown of outcomes at each time point if the abstract is selected for presentation.

Two-Year Revision Rates in Total Ankle Replacement Versus Ankle Arthrodesis: A Population-Based Propensity-Score-Matched Comparison from New York State and California.

Background:The aim of this study was to compare outcomes between total ankle replacement (TAR) and ankle arthrodesis (AA) for ankle osteoarthritis using real-world data.Methods:We used longitudinal claims data from New York State from October 2015 to December 2018, and from California from October 2015 to December 2017. The primary outcome was revision. Secondary outcomes were in-hospital complications and below-the-knee amputation. Propensity-score matching adjusted for differences in baseline characteristics. To determine predictors of the main outcome, each group was analyzed using multivariable Cox regressions.Results:There were 1,477 TAR procedures (50.2%) and 1,468 AA procedures (49.8%). Patients undergoing TAR were less likely to belong to a minority group and had fewer comorbidities compared with those undergoing AA. Crude analyses indicated that the TAR group had a lower risk of revision (5.4% versus 9.1%), in-hospital complications (<1% versus 1.8%), and below-the-knee amputation (<1% versus 4.9%) (p < 0.001 for all). However, in the propensity-score-matched analysis, the risk of revision was no longer significantly lower (TAR, 5.6% versus AA, 7.6%; p = 0.16). In the multivariable analyses, older age was predictive of a lower risk of revision after TAR (hazard ratio [HR], 0.96 [95% confidence interval (CI), 0.93 to 1.00]), but age was not predictive of revision after AA (HR, 0.99 [95% CI, 0.97 to 1.01]). Female patients were less likely to undergo revision after AA (HR, 0.61 [95% CI, 0.39 to 0.96]), but sex was not predictive of revision after TAR (HR, 0.90 [95% CI, 0.51 to 1.60]).Conclusions:The 2-year adjusted revision risk was 5.6% after TAR and 7.6% after AA. This difference did not reach significance. Older age was a predictor of lower revision risk after TAR. Men had a higher risk of revision than women after AA. The number of TAR procedures has now caught up with the number of AA procedures.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Total Joint Replacement of Ankle, Knee, and Hip: How Do Patients Perceive Their Operative Outcomes at 10 Years?

Background:Patient-reported outcomes (PROMs) are an integral part of national joint registers in measuring outcomes of operative procedures and improving quality of care. There is lack of literature comparing outcomes of total ankle replacement (TAR) to total knee replacement (TKR) and total hip replacement (THR). The aim of this study was to compare PROMs between TAR, TKR, and THR patient groups at 1, 5, and 10 years.Methods:Prospective PROMs from patients who underwent a TAR, TKR, or THR procedure between 2003 and 2010 were studied. Patients were divided into 3 groups based on their index joint replacement (hip, knee, or ankle). Patient demographics (age, gender, body mass index), patient-reported outcome scores (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], 36-Item Short Form Health Survey [SF-36]) and patient satisfaction scores (4-point Likert scale) at follow-up were compared between the 3 groups.Results:Data was available on 1797 THR, 2475 TKR, and 146 TAR patients. TAR patients were younger and reported fewer number of comorbidities. All 3 groups improved significantly from preoperative to 10 years for WOMAC scores (P < .001). For SF-36 scores at 10 years, the THR group (32.2% follow-up) scored the highest for 3 domains (P = .031) when compared to the TKR group (29.1% follow-up). All 3 groups had similar outcomes for 5 of 8 domains; P < .05). For patient satisfaction, the THR group reported overall 95.1% satisfaction followed by 89.8% for the TKR group and 83.9% in the TAR group (42.4% follow-up).Conclusion:In this cohort with diminishing numbers over the decade of time the patients were followed up we found that patients are equally happy with functional and general health outcomes from total ankle replacement vs other major lower extremity joint replacement. TAR surgery should be considered as a viable treatment option in this patient group.Level of Evidence:Level III, retrospective case series.

Return to Sport and Activity after Total Ankle Arthroplasty and Arthrodesis: A Systematic Review

Category:Ankle Arthritis; Ankle; OtherIntroduction/Purpose:There is no consensus regarding participation in sports and recreational activities following total ankle replacement (TAR) and ankle arthrodesis (AA). Better understanding on this topic will allow orthopaedic foot and ankle surgeons to set evidence-based goals and expectations with their patients in regards to postoperative activity recommendations and quality of life. We aimed to summarize the evidence on return to sport and activity after surgical management with either TAR or AA for ankle osteoarthritis (OA).Methods:A literature search of PubMed, MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed in January 2020. The bibliographies of all relevant publications were searched for further applicable studies. Included studies were required to report sport and activity outcomes in patients undergoing TAR and AA, with primary outcomes being percentage of sport participation and level of sport participation. Excluded studies were non-English and did not assess level of sport activity after TAR or AA.Results:Twelve studies met inclusion criteria for analysis. There were 1,270 ankle procedures, of which 923 TAR and 347 AA were performed. Mean reported patient age was 59.2 years old and mean BMI was 28 kg/m2. Mean follow-up was 43 months.Fifty-four percent of patients were active in sports preoperatively compared to 63.7% postoperatively (Figure 1). Mean preoperative activity participation rate was 41% in the TAR cohort, but improved to 59% after TAR, whereas preoperative activity participation rate of 73% was similar to postoperative rate of 70% in the AA cohort. The most common sports in TAR and AA groups were swimming, hiking, cycling, and skiing.Conclusion:Participation in sports activity is nearly 10% improved after surgical management of ankle OA. The existing literature demonstrated a large improvement in pre-to postoperative activity levels after TAR, with minimal change in activity after AA, however, AA patients were more active at baseline. The most frequent postoperative sports activities after surgical management of ankle OA are: swimming, hiking, cycling, and skiing. Despite preoperative participation in high-impact sports such as tennis, soccer, and running, these were consistently limited after surgery. This review of the literature will equip patients and physicians with the knowledge to appropriately establish realistic expectations for postoperative physical activity and return to sport goals.

Was Mark Reiley Right? A Outcome Analysis of Intramedullary Versus Extramedullaryalignment Referencing for Total Ankle Replacement

Category:Ankle Arthritis; AnkleIntroduction/Purpose:The purpose of this study was to report on the radiographic outcomes, clinical outcomes, and implant survivorship following extramedullary-referenced (EMr) versus intramedullary-referenced (IMr) total ankle replacement (TAR).Methods:From May 2007 to February 2018, a consecutive series of patients with end-stage tibiotalar osteoarthritis undergoing TAR for primary arthritis, post-traumatic arthritis, and inflammatory arthritis was enrolled in this study. Analyses were performed comparing IMr versus EMr components for patient-reported outcomes data, pre and postoperative radiographic ankle alignment, concomitant procedures, and complications. Kaplan-Meier survivorship analyses served to determine implant reoperation and revision surgery. Data was prospectively collected and retrospectively analyzed. A p-value of < 0.05 was considered significant for all statistical analyses.Results:A total of 340 TARs were included with 105 IMr TAR and 235 EMr TAR. The mean follow-up was 5.3 years ( +- 2.5, range 2-12). The absolute value for preoperative coronal alignment was significantly greater for IMr compared to EMr TAR (13.0 vs 6.4 degrees; p < 0.0001), but both groups achieved near neutral alignment postoperatively (1.4 vs 1.5 degrees; p=0.6655). The odds of having a concomitant procedure was 2.7 times higher in patients with an IMr TAR (OR 2.7, CI 1.7-4.4; p-value <0.0001). There were similar improvements in patient-reported outcome scores at one year and final follow up (all p > 0.05). The 5-year implant survivorship was 98.6.% for IMr versus 97.5% for EMr at final follow-up.Conclusion:Despite the IMr TAR group having more severe preoperative coronal and sagittal malalignment, both IMr and EMr TAR components had comparable postoperative alignment, patient-reported outcome scores, and complications. Among the patients with preoperative varus, valgus, or anterior distal tibial slope, the IMr patients achieved greater correction than the EMr patients. Although the 5-year implant survivorship was similar between the two cohorts with 98.6% survival for IMr TAR and 97.5% for EMr TAR, impending failures were greater for the mobile-bearing EMr TAR.

Economic Analysis and Clinical Outcomes of Short-Stay Versus Inpatient Total Ankle Replacement Surgery.

We aimed to perform an economic analysis and compare the clinical outcomes between inpatient and short-stay designation total ankle replacement (TAR). We performed a retrospective study on 178 consecutive patients undergoing primary inpatient versus short-stay designation TAR during the 2016 and 2017 fiscal years. Patient demographics, concomitant procedures, perioperative complications, patient-reported outcomes, and perioperative costs were collected. The mean age of our cohort was 62.5 ± 9.6 years (range, 30-88 years), with a significant difference in age (64.1 vs 58.5 years) (P = .005) and Charlson Comorbidity Index (3.3 ± 1.9 vs 2.3 ± 1.4; P = .002) for the inpatient and short-stay designation groups, respectively. At a mean follow-up of 29.6 ± 11.8 months (range, 12-52.3 months), there was no difference in complications between groups (P = .97). The inpatient designation TAR group had a worse baseline Short Musculoskeletal Functional Assessment (SMFA) function score (76.1; 95% CI, 70.5-81.6) than the short-stay designation TAR group (63.9; 95% CI, 52.5-75.3) while achieving similar final postoperative SMFA function scores for the inpatient (55.2; 95% CI, 51.1-59.2) and short-stay (56.2; 95% CI, 48.2-64.2) designation TAR groups (P > .05). However, the inpatient designation TAR group showed a significantly greater mean improvement in SMFA function score (20.9; 95% CI, 19.4-22.4) compared with the short-stay designation TAR group (7.7; 95% CI, 3.7-11.1) (P = .0442). The total direct cost was significantly higher for the inpatient designation group ($15 340) than the short-stay designation group ($13 002) (P < .001). While inpatient designation TARs were more comorbid, short-stay designation TARs were associated with a 15.5% reduction in perioperative costs, comparable complication rates, and similar final postoperative patient-reported outcome scores compared with inpatient TARs. Level III, retrospective comparative 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.

Hindfoot balancing in total ankle replacement: the role of supramalleolar osteotomies.

To compare the obtained deformity correction and clinical/functional outcomes between patients who underwent total ankle replacement (TAR) with or without a concurrent supramalleolar osteotomy (SMO) to address a varus and/or recurvatum deformity of the distal tibia. Data of 23 patients treated with an additional SMO to correct a varus and/or recurvatum deformity of the distal tibia at the time of TAR were prospectively collected. Twenty-three matched patients who underwent TAR only served as controls. The American Orthopaedic Foot and Ankle Society (AOFAS)-hindfoot scale and pain assessed on a Visual Analogue Scale (VAS) did not significantly differ between the two groups at the final follow-up (AOFAS-hindfoot scale SMO/TAR group = 82 ± 10; TAR group = 82 ± 12; VAS pain SMO/TAR group = 1 (range, 0-4); TAR group = 1 (range, 0-5)). Ankle range of motion (ROM) did not improve in the SMO/TAR group (pre-operative = 27 ± 13 degrees, last follow-up = 30 ± 9 degrees; P = .294), but did improve in the TAR group (pre-operative = 31 ± 14 degrees, last follow-up = 39 ± 14 degrees; P = .049). Two patients who underwent SMO/TAR showed non-union of the tibial osteotomy, and two patients who underwent TAR only suffered from an intra-operative medial malleolar fracture. An additional SMO during TAR in patients with a varus and/or recurvatum deformity of the distal tibia is not beneficial in most cases and should only be considered in pronounced multiplanar deformities.

Return to Sports and Activity After Total Ankle Arthroplasty and Arthrodesis: A Systematic Review.

There is no consensus regarding participation in sports and recreational activities following total ankle replacement (TAR) and ankle arthrodesis (AA). This systematic review summarizes the evidence on return to sports and activity after operative management with either TAR or AA for ankle osteoarthritis (OA). A literature search of MEDLINE, EMBASE, CINAHL, and Cochrane Library databases was performed. Risk of bias of included studies was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. Included studies reported sport and activity outcomes in patients undergoing TAR and AA, with primary outcomes being the percentage of sports participation and level of sports participation. Twelve studies met inclusion criteria for analysis. There were 1270 ankle procedures, of which 923 TAR and 347 AA were performed. The mean reported patient age was 59.2 years and the mean BMI was 28 kg/m2. The mean follow-up was 43 months. Fifty-four percent of patients were active in sports preoperatively compared with 63.7% postoperatively. The mean preoperative activity participation rate was 41% in the TAR cohort, but it improved to 59% after TAR, whereas the preoperative activity participation rate of 73% was similar to the postoperative rate of 70% in the AA cohort. The most common sports in the TAR and AA groups were swimming, hiking, cycling, and skiing. Participation in sports activity was nearly 10% improved after operative management of ankle OA with TAR and remains high after AA. The existing literature demonstrated a large improvement in pre- to postoperative activity levels after TAR, with minimal change in activity after AA; however, AA patients were more active at baseline. The most frequent postoperative sports activities after operative management of ankle OA were swimming, hiking, cycling, and skiing. Participation in high-impact sports such as tennis, soccer, and running was consistently limited after surgery. This review of the literature will allow patients and foot and ankle surgeons to set evidence-based goals and establish realistic expectations for postoperative physical activity after TAR and AA. Level III, systematic review.

Comparison of 25 ankle arthrodeses and 25 replacements at 67 months’ follow-up

IntroductionIn the treatment of osteoarthritis of the ankle, controversy persists between advocates of arthrodesis and of joint replacement. HypothesisResults of total ankle replacement (TAR) are equivalent to those of ankle arthrodesis (AA). Material and methodsA single-center continuous retrospective series included 50 patients (25 TAR, 25 AA) operated on by a single surgeon. TAR used the standard Salto® mobile-bearing prosthesis, and arthrodesis used screws or plates. Results were assessed clinically on AOFAS score, visual analog scale (VAS) and satisfaction questionnaire, and radiologically on X-ray and CT. Survivorship in the 2 procedures was estimated on the Kaplan Meier method. ResultsAt a mean 67 months’ follow-up (range, 40–105 months), mean AOFAS and VAS scores were significantly better in the AA group (74.1 and 1.9, respectively) than in the TAR group (67 and 3.5, respectively) (p<0.001). In the AA group, 80% of patients were satisfied or very satisfied, compared to 64% after TAR. Five-year survival without revision for non-union (AA) or implant removal (TAR) was similar between groups: AA, 96%; TAR, 90% (p=0.72). In contrast, survival with no revision procedures was significantly better with AA (96%) than TAR (75%) (p=0.03). DiscussionAt 5 years, surgical revision rates were significantly greater than after standard Salto® mobile-bearing TAR than for arthrodesis, notably due to onset of cysts; we therefore decided to abandon this implant. Level of evidenceIV, comparative retrospective study.

A Comparison of Cost and Complications of Total Ankle Arthroplasty and Ankle Arthrodesis for the Management of Ankle Arthritis

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a relatively common ailment that affects many people. The method of surgical management of this disease process is usually an ankle arthrodesis (AA) or a total ankle replacement (TAR). Traditionally, AA was viewed as the “gold standard”, however TAR has grown in popularity. Numerous studies have evaluated the risks and benefits of each of these treatments including satisfaction, biomechanics, and cost. The purpose of this study was to compare the cost and rate of complications for patients who underwent either an AA or TAR using a large database. Methods: Using the PearlDiver Technologies, Inc. database, Medicare patients who were diagnosed with ankle arthritis based on ICD-9 codes from 2005 to 2014 were analyzed. Patients were identified who underwent either AA or TAR utilizing ICD-9 procedure and CPT codes. These patient groups were evaluated for postoperative complications and reoperation rates. Subjects and associated costs were followed after the initial procedure. A cost analysis based on diagnosis and procedural codes was then performed on the separate groups, using a t-test to determine statistical significance. Data was analyzed with regards to standard demographic information as well as a metric of overall patient health status, the Charlson Comorbidity Index (CCI). Results: During the study period, 673,789 patients were identified with the diagnosis of ankle arthritis. Of those, 19,120(2.8%) underwent AA and 9,059 (1.3%) underwent TAR. While the yearly rate of AA performed remained stable, TAR was performed at increasing rates. The overall complication rate in the AA group was 24.9% with a 16.5% revision rate compared to 15.1% and 11.2% respectively in the TAR group (P&lt;0.001). Also, the AA group had a higher total reoperation rate. The CCI was found to be significantly lower in the TAR group at 4.5 versus 4.7 in AA patients (P&lt;0.001). Patients younger than 65 years old had both higher complication and reoperation rate. The average one-year cost associated with TAR was $12,566.15 and with AA was $6,967.32 (P&lt;0.001). Conclusion: While TAR was found to be a more expensive treatment option than AA in this large-scale database study, patients in this group had significantly lower complication rates. The reoperation rates were also lower in the TAR group. The CCI was noted to be slightly lower in the arthroplasty group, meaning these patients may have been healthier, representing a selection bias. Also, the patients that had complications were found to have a higher CCI on average. When choosing surgical intervention for end-stage ankle arthritis, patients should be counseled on cost differences and potential complications for TAR and AA.

Complications, Reoperations, and Postoperative Outcomes of Simultaneous Supramalleolar Osteotomy and Total Ankle Replacement in Misaligned Osteoarthritic Ankles in Comparison to Total Ankle Replacement Alone

Category: Ankle Arthritis Introduction/Purpose: A key for success in total ankle replacement (TAR) is a balanced ankle joint with a physiological loading of the implant, minimizing the wear of the polyethylene insert. Theoretically, in ankles with distal tibial deformities, this can be achieved with a correcting tibial resection cut. As an alternative, supramalleolar osteotomy (SMOT) can be used for balancing the ankle during TAR surgery. To date, however, no data exist whether a SMOT in addition to TAR results in better outcome over time, and which are the additional risks with such extensive surgery. The aim of the study was therefore 1) to determine the risk of a simultaneously performed SMOT in comparison to TAR only, and 2) to compare the postoperative clinical outcomes. Methods: Between 2002 and 2014, 23 patients (male, 12; female, 11; mean age 60 [22-72] years) underwent simultaneously a SMOT and a TAR for treatment of a severe misaligned osteoarthritic ankle (tibial anterior surface angle [TAS] &lt;84° [n=9] or &gt;96° [n=1], or tibial lateral surface angle [TLS] &lt;70° [n=13]) (SMOT&amp;TAR group). Statistical matching was applied to extract a subgroup out of 510 TAR patients from our prospectively collected database with the same baseline characteristics, including similar preoperative alignments (control group). The matched 23 TAR patients (male, 16; female, 7; mean age 58 [35 - 79] years) were compared regarding additional procedures, complications and reoperations. Pre- and postoperative alignment measured on radiographs and clinical outcome (range of motion [ROM], pain on the visual analogue scale [VAS] and AOFAS hindfoot score) were compared. Results: While more additional osteotomies were done in the SMOT&amp;TAR group (calcaneus, 5:1; fibula, 7:1), more ligament reconstructions and tendon transfers were done in control group (ligament reconstruction, 0:6; tendon transfer, 0:6). There was no difference, neither in the complication rate nor in the reoperation rate between both groups. However, there was a tendency of instability, subsequent polyethylene wear and cyst formation in the TAR group. The postoperative TAS was closer to neutral in the SMOT&amp;TAR (pre- to postoperatively: 82.9° to 90.4° vs. 82.6° to 87.8°). While ROM was lower in the SMOT&amp;TAR (30°) than in the TAR group (39°) (p=0.01), there was no difference in the clinical outcome (VAS pain 1.2 vs. 1.5 [p=0.58], AOFAS score 82 vs. 82 [p=0.99]). Conclusion: A SMOT performed simultaneously with TAR for the treatment of a severely deformed ankle resulted in a more neutral and better balanced ankle, and it was not associated with a greater risk of complications or reoperations. The only disadvantage was a slightly smaller ROM. Thus, SMOT should be considered in TAR with greater hindfoot deformities at the distal tibia as it is more powerful to address deforming forces. As shown, SMOT and TAR can be done simultaneously without taking greater risks.

Comparing Sports Activity Following Total Ankle Replacement Versus Ankle Arthrodesis

Category: Ankle, Ankle Arthritis, Sports Introduction/Purpose: Total ankle replacement (TAR) and ankle arthrodesis (AA) are two common surgical treatment modalities for end stage tibiotalar arthritis. A key deciding point between the two is anticipated functional outcome postoperatively, especially in regards to sports related activities. However, there is a paucity of data available to help advise patients in their decision making. While TAR provides a theoretical benefit of improved functionality, the outcomes of several European studies have shown mixed results. These studies are limited by small sample size, obsolete TAR implants not used in the United States, and nonspecific outcome measures. The purpose of this study was to compare postoperative sports activity levels following modern TAR and AA in a U.S. population, which may benefit surgical decision making and guide patient expectations. Methods: We conducted a retrospective comparative study that consisted of patients who underwent a TAR (N=62) or AA (N=51) between 2009-2015. The mean age of the arthrodesis group was 57.7 years ± 12.12 (28.84-85.26). There were 27 male participants and 24 female participants. The TAR group had 31 male and 31 female participants with a mean age of 64.9 years ± 8.57 (45-79.6). Exclusion criteria included paralysis, rheumatoid arthritis, revision surgery, incomplete pre- and post-operative scores, and follow up less than 2 years. General health and foot-ankle function were assessed using the SF-12 Health Survey and the revised Foot Function Index (FFI-R) preoperatively and at final follow-up. In addition, activity levels were assessed using a Return to Activities Following Surgery questionnaire that was administered at final follow up. This form included a Visual Analog Scale for Pain, satisfaction questions, and a list of 25 activities. Patients were asked to record their current level of activity, ability to participate pre- and post-surgery, and whether their desired level was met. All three measurements tools were compared between both treatment groups. Results: The SF-12 physical score both groups significantly increased postoperatively from 33.18 ± 10.37 to 43 ± 10.32 for AA’s and from 32.88 ± 9.44 to 45.81 ± 12.94 (p &lt; 0.001) for TAR’s. The FFI scores showed a significant increase in both groups (p &lt; 0.001). In the AA group, 88% of patients returned to work and would repeat the surgery, compared to 92% of patients in the TAR group. In terms of satisfaction and pain, the TAR group was more satisfied (1.78 vs. 1.44) and had less postoperative pain (1.32 vs. 2.56 p &lt; 0.05). The AA group reported a significant increase in six activities including: golf (p &lt; 0.05), weight lifting, and walking (p&lt;0.001), while the TAR group reported significant increase in 15 activities, including hiking, tennis, and yoga (p&lt;0.001). Conclusion: Our study revealed a significant increase in general physical function, foot function, and activity level in both groups. The TAR group was able to perform a wider range of activity and sports compared to the AA group. Overall, TAR patients were significantly more satisfied with their procedure compared to AA patients.