Total Ankle Replacement Patients Research Articles

Association of Diabetes Mellitus and Immediate Postoperative Complications after Total Ankle Replacement: A Large Database Analysis

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total Ankle Replacement (TAR) has rapidly grown in popularity over the last fifteen years as a treatment for ankle arthritis. With this growth, it is imperative to understand risk factors that may predispose patients to complications following the procedure. This information can be valuable in generating treatment plans and facilitating conversation regarding risks and benefits of those plans. Current literature on TAR-related outcomes is limited in timeframe and scope and does not investigate the association of diabetes with common post operative complications. The objective of this study was to perform a retrospective database analysis to quantify the risk of 90-day complications in patients with diabetes undergoing TAR when compared to patients without diabetes undergoing TAR. Methods: The TriNetX database was utilized for this study. Patients who underwent TAR were identified and stratified by those with a history of diabetes mellitus and those without a history of diabetes mellitus of any type. The cohorts were 1:1 propensity matched based on demographic information and medical history. The 90-day complication rates for readmission, inpatient service use, opioid use, anesthesia use, periprosthetic fracture, deep vein thrombosis, and wound dehiscence were calculated using chi-square analysis. Results: n=5,984 TAR patients were identified. 52% were male and 48% female with mean age of 73±10 years. There was a n=1,331 patients in each the patients with diabetes and without diabetes groups after cohort analysis and propensity matching. TAR patients with diabetes had a significantly higher 90-day odds ratio of inpatient service use (OR: 1.675, 95% CI 1.3082-2.144; p< 0.001). There was no significant difference between groups in opioid use (OR: 1.13, 95% CI 0.941-1.357; p=0.1908), anesthesia use (OR: 1.335, 95% CI 0.906-1.965; p=0.1424), and wound dehiscence (OR: 1.313, 95% CI 0.829-2.08; p=0.2445); Table 1. There was insufficient data to determine the role of diabetes on critical care services, periprosthetic fracture, and DVT within 90 days of TAR. Conclusion: TAR is a developing operation for ankle arthritis and little data exists on diabetes related perioperative complications. The results of this study show that although diabetes is significantly associated with a higher rate of inpatient service use, it may not have as large a role in opioid use, anesthesia use, and wound dehiscence in the immediate postoperative period. More information is still needed to address long term outcomes and the role diabetes plays in other postoperative complications.

Does Arthroplasty Really Protect the Hindfoot? A 13 year retrospective review of 516 cases for Further Hindfoot Procedures Following Ankle Arthrodesis vs Total Ankle Replacement

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Total Ankle Replacement (TAR) have a potential advantage of protecting further degradation of hindfoot joints by maintaining ankle joint motion. However, there is no study to our knowledge that directly compares hindfoot outcomes between TAR and Ankle Arthrodesis (AA) in the long term. Sokolowski et al. found that 68% of TAR patients had no radiological progression of subtalar arthritis after TAR, and 4% went on to fusion. Other studies have looked at 5 year outcomes finding higher hindfoot fusion rates post AA. However, no evaluation of the other hindfoot joints was made and no comparison made to other treatment. This study aimed to analyze the long-term rates of symptomatic hindfoot arthritis resulting in further procedures following TAR versus AA. Methods: We performed a retrospective review of all patients at our centre who had a TAR or AA since 2002. Case notes and imaging were reviewed and all instances of hindfoot treatment (injections or surgical procedures) noted. Patient were excluded who had no documentation, were followed up at other hospitals, had prior hindfoot fusion, or were having staged surgeries at the time of index treatment. Chi squared analysis was used to compare the cohorts. Results: Analysis revealed 428 eligible cases (275 TAR, 153 AA). TAR patients were older (mean age: 62 vs. 52 years, p=0.00001). Average follow up was 12.6 (1 – 21) years for TAR and 12.1 (1-21) years for AA. TAR showed lower rates of overall further hindfoot procedures compared to AA (14% vs. 24%, p=0.01), with significantly fewer hindfoot fusions (4% vs. 14%, p=0.0002). Revision rates were similar between groups (6% TAR vs. 4% AA, p=0.99). Conclusion: This study highlights higher rates of symptomatic hindfoot arthritis requiring intervention in AA compared to TAR. TAR appears to offer advantages in hindfoot preservation, with similar revision rates. Prospective studies integrating patient-reported outcomes are warranted to assess TAR versus AA efficacy on hindfoot function and overall well-being. Our findings advocate for TAR as the primary treatment for end-stage ankle arthritis, if appropriate, when considering symptomatic progression in management decisions.

Is Age but a Number? Age-Related Outcomes for Total Ankle Replacement

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle replacement (TAR) is increasingly performed on patients across a wide age spectrum, though historically it has been reserved for older patients (>60). In this study, we seek to determine how age influences patient outcomes. Methods: This is a retrospective, comparative cohort study of consecutive patients that underwent TAR from 2004-2021. Patients were categorized into three age groups: < 55, 56-70, and >70. We evaluated surgical complications and patient-reported outcome measures, including Ankle Osteoarthritis Pain & Disability Scores (AOS) and Short Form-36 Health Survey (SF-36). Analysis of covariance was performed, adjusting for patient factors. Results: We reviewed 812 consecutive TARs from a single-centre with 407 (50.1%) male and mean BMI of 29.8±5.78. The median follow up was 64.0 months (IQR,76.0). Patients ≤55 had worse pain preoperatively than both older patient groups (p=0.03) and worse mental health (p< 0.001), however, this difference was not observed in postoperative AOS pain (p=0.15) or SF-36 MCS scores (p=0.87). Patients >70 had worse physical health than patients 56-70 (p=0.02) and less change in pre- to postoperative SF-36 PCS scores (p=0.02). Patients from all groups improved similarly according to the AOS pain (p=0.15) and disability (p=0.12). Conclusion: These results show that TAR patients younger than 55 have worse pain and mental health preoperatively but have similar long-term clinical outcomes to patients 56 and older.

Outcome after total ankle replacement or ankle arthrodesis in end-stage ankle osteoarthritis on the basis of german-wide data: a retrospective comparative study over 10 years

BackgroundIn symptomatic end-stage osteoarthritis of the ankle joint, total ankle replacement and ankle arthrodesis are the two primary surgical options for patients for whom conservative treatment fails. Published revision rates are often biased and difficult to compare. In this study, unplanned reoperation rates and revision rates were determined for both surgical interventions based on a large dataset, and risk factors for unplanned reoperations were identified.MethodsGerman-wide health data of the largest German health-care insurance carrier between 2001 and 2012 were retrospectively analyzed, and unplanned reoperation rates within 10 years were determined for index surgeries conducted in 2001 and 2002. Unplanned reoperation rates within 5 years for index surgeries conducted in 2001/2002 were compared to index surgeries conducted in 2006/2007. Multivariate logistic regression was used to identify risk factors for unplanned reoperations.ResultsAfter ankle arthrodesis, 19% (95% confidence interval [CI], 16–22%) of 741 patients needed to undergo an unplanned reoperation within ten years. After total ankle replacement, the unplanned reoperation rate was 38% [95% CI, 29–48%] among 172 patients. For initial surgeries conducted at a later date, unplanned reoperation rates within five years were 21% [95% CI, 19–24%] for 1,168 ankle arthrodesis patients and 23% [95% CI, 19–28%] for 561 total ankle replacement patients. Significant risk factors for unplanned reoperations after ankle arthrodesis in the initial cohort were age < 50 years (odds ratio [OR] = 4.65 [95% CI 1.10;19.56]) and osteoporosis (OR = 3.72 [95% CI, 1.06;13.11]); after total ankle replacement, they were osteoporosis (OR = 2.96 [95% CI, 1.65;5.31]), Patient Clinical Complexity Level (PCCL) grade 3 (OR = 2.19 [95% CI, 1.19;4.03]), PCCL grade 4 (OR = 2.51 [95% CI, 1.22;5.17]) and diabetes mellitus (OR = 2.48 [95% CI, 1.33;4.66]). Kaplan-Meier analyses including 1,525 ankle arthrodesis patients and 644 total ankle replacement patients revealed an average unplanned reoperation-free time of approximately 17 years for both procedures.ConclusionsSimilar revision rates and unplanned reoperation rates for both procedures in the later-date cohort can likely be attributed to a learning curve for surgeons as well as advances in implant design. This analysis of billing health insurance data supports an increase in total ankle replacement surgeries.

ARE TOTAL ANKLE ARTHROPLASTIES MORE PROTECTIVE OF THE HINDFOOT JOINTS THAN ANKLE ARTHRODESIS? A 13-YEAR AVERAGE RETROSPECTIVE REVIEW OF 516 CASES

One assumed function of Total Ankle Replacement (TAR) is that by maintaining ankle joint motion we can protect the other hind foot joints from further degredation1. However, there is no work to our knowledge that compares hindfoot outcomes between TAR and arthrodesis. Sokolowski et al. found that 68% of TAR patients had no radiological progression of subtalar arthritis after TAR, and 4% went on to fusion2. However, no evaluation of the other hindfoot joints was made and no comparison made to other treatment. We performed a retrospective review of all patients at our centre who had had a TAR or ankle arthrodesis since 2002. Case notes and imaging were reviewed and all instances of hindfoot treatment (injections or surgical procedures) noted. Patients were excluded who had no documentation, were followed up at other hospitals, had prior hindfoot fusion, or were having staged surgeries at the time of index treatment. Chi squared analysis was used to compare the cohorts. 214 arthrodesis cases and 302 TAR were eligible. The average age was 57. Average time to follow up was 13 years (4–21). At the time of abstract submission 107 sets of notes had been reviewed fully. Full analysis will be performed by conference. 14% of TAR patients went on to have further procedures to the hindfoot joints while 35% of arthrodesis patients had further procedures (p=0.014). There was also a significant difference in the number of patients progressing to fusion of a further hindfoot joint between groups (TAR- 4%, arthrodesis- 20%, p=0.01). These data suggest that TAR are protective of symptomatic change of hindfoot joints. Patients with TAR had fewer hindfoot fusions than those with arthrodesis and also fewer procedures of any form, including injections.

Defining the Patient Acceptable Symptom State (PASS) for PROMIS After Total Ankle Replacement.

Although patient-reported outcomes (PROs), such as the Patient-Reported Outcomes Measurement Information System (PROMIS), are a key element of evaluating success after total ankle replacement (TAR), many do not explicitly state a key factor of postoperative success: is the patient satisfied with their outcome after TAR? The patient acceptable symptom state (PASS) represents the symptom threshold beyond which patients consider themselves well. This study aimed to establish the PROMIS thresholds for the PASS in a primary cohort of TAR patients. This single-institution study included 127 primary TAR patients with preoperative and 2-year postoperative PROMIS scores. At 2 years postoperatively, patients answered 2 PASS anchor questions (Satisfaction, Delighted-Terrible scale) with Likert-scale responses. PASS thresholds with 95% confidence intervals (CIs) were calculated from PROMIS scores using an anchor-based method. Using a bootstrapping technique with 1,000 iterations, the Youden index was calculated to determine the best specificity and sensitivity coordinates to maximize their combination. Finally, preoperative variables associated with the likelihood of achieving the PASS were assessed. There was a strong association between PASS thresholds and PROMIS domains, especially Pain Interference (PASS threshold of <56.0, area under the receiver operating characteristic curve [AUC] = 0.940), Pain Intensity (<48.4, AUC = 0.936), and Physical Function (>44.7, AUC = 0.883). The likelihood of achieving the PASS was not affected by age, race, gender, American Society of Anesthesiologists (ASA) class, body mass index, or severity of ankle deformity. Patients with worse preoperative Physical Function and Global Mental Health scores were less likely to meet the PASS threshold for Physical Function postoperatively (p = 0.028 and 0.041). The ability to reach the PASS after TAR was most strongly associated with postoperative PROMIS pain scores. However, PASS thresholds were generally poorer than population means. This demonstrates that patients do not need to reach normal pain or physical function levels to have an acceptable symptom state after TAR. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Lessons From Revision Total Ankle Replacement: Tibias Fail Earlier, and Taluses Fail Later (and Fail Again).

The literature on survivorship and outcomes after revision total ankle replacement (TAR) in the modern era is limited. This study aimed to describe the timing to revision and survivorship after revision TAR. We hypothesized that tibial-sided failures would occur earlier after the primary TAR, and secondary revisions after failure of revision TAR would occur more due to talar-sided failures than tibial-sided failures. This is a single-institution retrospective study of TAR patients with minimum 2-year follow-up. Revision TARs (defined as exchange of tibial and/or talar components) for aseptic causes with any implant were included. Etiology of failure necessitating revision and ultimate outcomes after revision (survival of TAR revision, additional revision, conversion to fusion, and below-knee amputation [BKA]) were recorded. There were 46 revision TARs, with mean age of 60.6 (range: 31-77) years and mean 3.5 years' follow-up postrevision. Revisions for tibial failure occurred significantly earlier (n = 22, 1.3 ± 0.5 years after index procedure) than those for talar failure (n = 19, 2.3 ± 1.7 years after index procedure) or combined tibial-talar failure (n = 5, 3.4 ± 3.4 years after index procedure) (P = .015). Revisions for tibial-only failure had better survival (95.5%) than revisions for talar or combined tibial-talar failures: 26% of talar failures and 20% of combined tibial-talar failures underwent ≥1 revisions. Of the 6 additional revisions after failure of the talar component, 1 ultimately underwent BKA, 2 were converted to total talus replacement, 2 were revised to modular augmented talar components, and 1 was treated with explant and cement spacer for PJI after the revision. TAR tibial failures occurred earlier than talar failures or combined tibial-talar failures. Revisions for talar failures and combined tibial-talar failures were more likely to require additional revision or ultimately fail revision treatment. This is important given the consequences of talar implant subsidence, bone necrosis, loss of bone stock, and limited salvage options.

Lessons from Revision Total Ankle Replacement: Tibias Fail Early, and Taluses Fail Late (And Fail Again)

Introduction/Purpose: With the last decade’s surge in total ankle replacement (TAR), there is an anticipated commensurate increase in the number of revisions that orthopaedic foot and ankle surgeons will encounter. The salvage and implant options to deal with a failed primary TAR are expanding. However, the literature on survivorship and outcomes after revision TAR in the modern era is relatively limited. What’s more, little is known about the risk factors for further revision or failure of revision TAR. This study aimed to describe the timing to and survivorship after revision TAR. We hypothesized that tibial-sided failures would occur earlier after the index surgery, and secondary revisions after failure of revision TAR would occur more due to talar-sided failures than tibial-sided failures. Methods: This is a single-institution retrospective cohort study of TAR patients (2012-2022) with minimum 2-year follow-up. Revision TARs (defined as exchange of tibial and/or talar components) with any implant (Cadence, Inbone, Invision, Infinity, Salto, STAR, Vantage, Zimmer; or custom total talus replacement [TTR]) were included. Five surgeons contributed patients. Demographics, primary and revision surgical data, and postoperative complications were recorded. Etiology of failure necessitating revision (tibial failure, talus failure, combined failure) and ultimate outcomes after revision (revision TAR survived, additional revisions, conversion to fusion, below-knee-amputation [BKA]) were recorded. Revisions for periprosthetic joint infection (PJI) and conversions to fusion were excluded. There were 59 ankles that underwent revision for any cause. Excluding 9 2-stage revisions for PJI and 3 conversions to ankle or tibiotalocalcaneal fusion, there were 47 ankles that underwent revision TAR that were included for analysis. Chi-square and ANOVA tests were used to compare risk factors and timing for failure. Results: There were 47 revision TARs, with mean age 60.6 (range: 31-77) years, mean BMI 29.5 kg/m2, 19 (40.4%) females, and mean 3.5 years follow-up. Revisions for tibial failure (n=22) occurred significantly earlier (1.3 ± 0.5 years) than those for talus failure (n=19, 2.3 ± 1.7 years) or combined tibial/talus failure (n=6, 2.9 ± 3.3 years) (P=0.048). Revisions for tibial-only failure had significantly better survivorship (95.5%) than revisions for talus or combined tibia/talus failures: 26% of talus failures and 33% of combined tibia/talus failures underwent at least one more revision (P=0.033). Of the 7 failures after revision talus, 2 ultimately underwent BKA, 2 were converted to TTR, 2 were revised to modular stemmed talus implants, and 1 was treated with explant and cement spacer for PJI. Conclusion: This study demonstrates that TAR tibial failures occur earlier than talus failures or combined tibial/talus failures. When patients with isolated tibial failure undergo revision of both tibial and talar components, they usually do well with good survivorship post-revision. However, revisions for talar failures and combined tibial/talar failures occur later but are more devastating: nearly 1/3 go on to a second revision. This is important given the consequences of talar implant subsidence, bone necrosis, loss of bone stock, and limited salvage options. As TAR utilization expands, it is imperative to develop implants and surgical strategies to maximize success for revision surgery. Flowchart of failures after revision TAR. PJI = periprosthetic joint infection. TTC = tibiotalocalcaneal. BKA = below-knee amputation. Tibial implant geometry included: Low-pro = lowprofile tibial implant. Stem = stemmed tibial implant. Keel = keeled tibial implant. Talus implant geometry included: chamfer/round and flat-cuttalus.

Defining the Patient Acceptable Symptom State (PASS) for PROMIS After Total Ankle Replacement

Category: Ankle Arthritis; Other Introduction/Purpose: Patient-reported outcomes (PROs), such as PROMIS, are a key element of evaluating success after total ankle replacement (TAR). To date, most PROs are described using absolute values or parameters like the minimum clinically important difference. However, these interpretations do not explicitly tell the surgeon the most important factor of postoperative success: is the patient satisfied with their outcome after TAR? The patient acceptable symptom state (PASS) is a novel PRO metric that attempts to bridge this gap. PASS represents the symptom threshold above which patients consider themselves well. This study aimed to establish the PROMIS thresholds for PASS in a primary cohort of TAR patients. We hypothesized that TAR patients would meet PASS and that PASS would vary with demographic variables. Methods: This is a single-institution retrospective cohort study of primary TAR patients (n=127; mean age 63.2 years; mean BMI 29.0 kg/m2; 58% male) with preoperative and 2-year postoperative PROMIS scores (domains: Physical Function, Pain Interference, Pain Intensity, Global Mental Health, Global Physical Health, &amp; Depression). At 2 years postoperatively, patients also answered 2 PASS anchor questions with Likert-scale responses: 1) Are you satisfied with the results of your surgery?; and 2) the Delighted- Terrible symptom scale. PASS thresholds with 95% confidence intervals (CI) were calculated using the anchors “Very satisfied” or “Satisfied” for question 1 and “Delighted,” “Pleased,” or “Mostly Satisfied” for question 2. Using bootstrapping technique with 1000 iterations, the Youden Index was then calculated to determine the best coordinates of specificity and sensitivity to maximize the Area Under the Curve (AUC). Finally, we analyzed preoperative variables (demographics, clinical/surgical data, and preoperative PROMIS scores) on the likelihood of achieving PASS. Results: There was a strong association between PASS thresholds and PROMIS domains, especially Physical Function (PASS threshold &gt;44.7, AUC 0.883), Pain Interference (&lt; 56.0, AUC 0.940), and Pain Intensity (&lt; 48.4, AUC 0.936). Covariate stratification demonstrated that the likelihood of achieving PASS was not affected by age, race, gender, ASA score, or BMI. PASS was less likely to be achieved by patients who had undergone prior orthopaedic surgery (P=0.013). Patients with diabetes mellitus and peripheral vascular disease were less likely to meet PASS for Physical Function (P=0.010, P=0.037), but did meet PASS for Pain domains. Patients with worse preoperative Physical Function and Depression scores were less likely to meet PASS for Physical Function postoperatively (P=0.028, P=0.041), but achieved similar PASS for Pain Interference and Pain Intensity domains. Conclusion: After TAR, the ability to reach the postoperative PASS was most strongly associated with postoperative pain scores, as evidenced by the Pain Interference and Pain Intensity domains. However, the thresholds for PASS were generally lower than population means. This demonstrates that TAR patients do not need to reach normal pain or physical function levels in order to have an acceptable symptom state postoperatively. Moreover, the ability to achieve PASS was not affected by demographic variables. Further research on PASS is warranted, and may shift how surgeons and researchers evaluate TAR patients pre- and post-operatively.

Statistical Shape Modeling Enables Identification of Subtalar Contact Stress Differences Following Tibiotalar Arthrodesis and Total Ankle Replacement

Category: Hindfoot; Ankle Arthritis Introduction/Purpose: Clinical studies have shown 32% of patients with a TAR progress to subtalar OA within 5 years, whereas 78% of patients with a tibiotalar arthrodesis presented with subtalar OA by 7.5 years. Higher rates of subtalar OA after arthrodesis may be explained by a transfer of ankle forces and stress through the adjacent subtalar joint while TAR may mitigate these changes. The objective of this study was to compare subtalar joint contact stresses between patients treated with tibiotalar arthrodesis and total ankle replacement (TAR) during an overground walking activity using correspondence particles to enable regional analysis. Methods: With IRB approval, ten individuals with unilateral tibiotalar arthrodesis and six individuals with unilateral TAR were imaged with biplane fluoroscopy during overground walking. Discrete element analysis (DEA) was performed to estimate subtalar joint contact stress using the tracked bone models. Cartilage was modeled using linear-elastic material properties (E=12 MPa, v=0.42) and uniformly extruded compressible surfaces from rigid subchondral bone (0.98 mm talar side, 0.75 mm calcaneal side1). A calcaneal statistical shape model (SSM) was created and resulting correspondence particles served as registered locations for comparison of cumulative stress across three phases of normalized stance (loading-response 0-24%, mid 25-54%, and terminal 55- 87%). Two-sample t-tests or Wilcoxon rank-sum tests were used to evaluate differences (p &lt; 0.05) in cumulative contact stresses at each correspondence particle within the 3 phases based upon Shapiro-Wilk findings of normality. Results: There were significant differences in contact stress exposure across all three phases of gait. Differences were identified along the superior-medial aspect of the posterior facet and within the anterior facet (Figure 1). Higher cumulative stresses were observed along the border of the posterior facet and in the medial facet. This model is limited by a lack of validation, uniform cartilage thickness assumptions applied across groups, and that DEA only estimates contact stress without consideration of shear. Conclusion: This study was the first to localize regional differences in subtalar joint stress for patients having undergone TAR and tibiotalar arthrodesis. Interestingly, TAR patients experienced higher stress in this study compared to those with arthrodeses. These ostensibly counterintuitive findings of higher TAR stress may relate to the pre-existence of subtalar OA which is a common indication of TAR versus fusion.

Home and Outpatient Physical Therapy Utilization Following Total Ankle Replacement.

Physical therapy (PT) following total ankle replacement (TAR) is often considered, but guidelines for its use are not standardized. Although patient factors may dictate recommendations, this retrospective cohort study aims to characterize baseline utilization practices to set the stage for establishing generalizable recommendations. TAR patients were identified from the 2010-2019 M91 Ortho PearlDiver data set based on administrative coding. Patient factors were extracted, including age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which patients' surgery was performed (Midwest, Northeast, South, West), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, and frequency of home or outpatient PT utilization in the 90 days following TAR were identified. Inpatient PT was not captured. Univariate and multivariate logistic regression analyses allowed identification of predictive factors for PT utilization. Of 5412 TAR patients identified, postoperative PT services were used by 2453 (45.3%). Most PT was outpatient (38.3% of the study population) compared to home (4.1% of the study population). Weekly utilization of PT was greatest in the first week following surgery (17.7% of PT visits) and thereafter followed a roughly bell-shaped curve, with utilization greatest at 7 weeks following surgery (14.9% of PT visits).Independent predictors of PT utilization following TAR included having surgery performed in the Midwest (relative to the South, OR 1.37, P < .0001), Northeast (OR 1.20, P = .0217), or West (OR 1.26, P < .0021) and having commercial (relative to Medicare, OR 1.87, P < .0001) or Medicaid insurance (OR 1.46, P = .0239). Of 5412 TAR patients, 42.5% used PT within 90 days of surgery. PT utilization was highest in the first and seventh weeks following surgery, and demographic predictors of PT use were defined. Through identification of timing and predictors of PT utilization following TAR, PT care pathways may be better defined. Level III, retrospective cohort study.

Emergency Department Visits Within 90 Days of Total Ankle Replacement.

Total ankle replacement (TAR) utilization in the United States has steeply increased in recent decades. Emergency department (ED) visits following TAR impacts patient satisfaction and health care costs and warrant exploration. This retrospective cohort study utilized the 2010 to 2019 M91Ortho PearlDiver data set to identify TAR patients with at least 90 days of follow-up. PearlDiver contains billing claims data across all sites of care throughout the United States for all indications for care. Patient factors extracted included age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which surgery was performed, insurance plan, and postoperative hospital length of stay. Ninety-day postoperative ED visit incidence, timing, frequency, and primary diagnoses were identified and compared to 1-year postoperative ED visit baseline data. Univariate and multivariate logistic regression analyses were used to determine risk factors for ED visits. Of 5930 TAR patients identified, ED visits within 90 days were noted for 497 (8.4%) patients. Of all ED visits, 32.0% occurred within 2 weeks following surgery. Multivariate analysis revealed several predictors of ED utilization: younger age (odds ratio [OR] 1.35 per decade decrease), female sex (OR 1.20), higher ECI (OR 1.32 per 2-point increase), TAR performed in the western US (OR 1.34), and Medicaid coverage (OR 2.70; 1.71-4.22 relative to Medicare) (P < .05 each). Surgical site issues comprised 78.0% of ED visits, with surgical site pain (57.0%) as the most common problem. Of 5930 TAR patients, 8.4% returned to the ED within 90 days of surgery, with predisposing demographic factors identified. The highest incidence of ED visits was in the first 2 postoperative weeks, and surgical site pain was the most common reason. Pain management pathways following TAR should be able to be adjusted to minimize the occurrence of postoperative ED visits, thereby improving patient experiences and decreasing health care utilization/costs. Level III, retrospective cohort study.

An Analysis of 50 Consecutive Total Ankle Replacements Undergoing Preoperative Computerized Tomography Scan-Based, Engineer-Provided Planning From a Single Noninventor, Nonconsultant Surgeon

Preoperative computerized tomography (CT) scan-based, engineer-provided alignment plans and patient-specific pinning blocks for total ankle replacement (TAR) are available for use in the United States. However, nonbiased studies that justify the additional expense associated with this technology through support of the marketed benefits of less procedural complexity, less intraoperative radiation and reduced surgical time, are lacking. Therefore, to verify the manufacturer's proposed benefits, we sought to investigate our experience with this preoperative CT scan-based, engineer-provided plan and patient-specific pinning blocks during primary TAR. In review of our 50 TAR patients, we found that “perfect” radiographic alignment was not consistently achieved and the accuracy of component prediction was modest. Furthermore, the preoperative plans and patient-specific pinning blocks did not simplify the complexity of our operations since the operative time, intraoperative image intensification time and radiation dose per case all exceeded published historical TAR controls. Interestingly, we identified a significant difference in placement accuracy between the arced and flat-top talar component types that were implanted with the arced being more frequently malaligned. We did not find associations between preoperative deformity severity and accuracy of postoperative alignment. These findings suggest that it is imperative to have surgeons continue to rely on their own surgical planning and experience to achieve optimum radiographic alignment rather than depending on engineer-based recommendations or “surface matched” pinning blocks. Ultimately, we were unable to support the purported benefits of this CT scan-based, engineer-provided alignment plan and patient-specific pinning blocks for this manufacturer's primary TAR systems.

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.

Comparison of Short-Term Outcomes After Total Ankle Replacement and Ankle Arthrodesis: An ACS-NSQIP Database Study.

Over the past 2 decades, several studies comparing intermediate- and long-term outcomes after total ankle replacement (TAR) versus ankle arthrodesis (AA) have reported differing rates of complications and outcomes. Recently, there has been a dramatic increase in patients undergoing TARs without any epidemiologic studies examining the short-term and perioperative complications. The purpose of this prognostic study was to compare perioperative outcomes after TAR and AA using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database between 2012 and 2017. Patient data were collected from the NSQIP database for surgeries between January 2012 and December 2017 using Current Procedural Terminology codes 27700, 27702, 29899, and 27870. Patients were excluded if treated for fracture, infection, or revision procedures. The outcomes of interest were readmission and reoperation related to initial surgery, surgical site infections, and hospital length of stay. There were 1214 patients included-1027 (84.6%) TAR and 187 (15.4%) AA. The TAR patients were older, had a lower body mass index, and were less likely to have insulin-dependent diabetes. Readmission rate and length of stay was similar between groups. Multivariate regression revealed higher anesthesia severity scores (P = .0007), diabetes mellitus (P = .029), and AA (P = .049) had positive correlations with adverse outcomes. We report a lower complication rate with TAR than previously described. AA arthrodesis is associated with a higher risk of perioperative complications, including deep surgical site infections and reoperations. There were no differences between the 2 groups comparing superficial infection, wound dehiscence, or readmissions in the first 30 days.Levels of Evidence: Level V.

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.

The motion between components in a mobile-bearing total ankle replacement measured by cone-beam CT scanning

BackgroundTo measure the motion of polyethylene insert and implant components of mobile-bearing total ankle replacement (TAR) by cone-beam CT scanning. Methods10 TAR patients with high amount of clinical motion after the CCI implant (Ceramic Coated Implant; Wright Medical Technology, Arlington, TN, USA) with average age at operation 64,3 years (range 47–84) and average clinical total range of motion 42 degrees (range 35–55) were included. ResultsThe average total range of motion between the insert and the tibial component was 0.8mm (range 0–2) in the coronal plane, and 2.9mm (range 1–6) in the sagittal plane. There was wide variation in the axial rotation measurements between the components. ConclusionWe found measurable motion between the mobile-bearing insert and the tibial component in all planes. The relevance of this motion to the function and long-term survival of the TAR remains to be determined.

Reoperation Rates Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Posttraumatic Indications.

This studied aimed to compare rates of reoperation for patients who received primary ankle arthrodesis (AA) versus total ankle replacement (TAR) for posttraumatic indications between 2010 and 2016 Q2 using a nationwide claims database. A retrospective cohort study analyzing patients who received primary AA or TAR for posttraumatic indications was performed using PearlDiver. Reoperations assessed included prosthetic joint infection (PJI), hardware removal, adjacent joint fusion, and local open reduction internal fixation (ORIF). Multivariable logistic regression was used to compare rates of reoperations at 1 and 2 years postdischarge. A total of 862 (74%) patients received AA and 318 (26%) patients underwent TAR for a posttraumatic indication. At 1 year, 305 (35.4%) AA patients had at least 1 reoperation compared with 55 (17.3%) TAR patients (OR 2.32; 95% CI, 1.68-3.26). At 2 years, 364 (42.2%) AA patients and 66 (20.8%) TAR patients had at least 1 reoperation (OR 2.51; 95% CI, 1.84-3.45). ORIF, hardware removal, and adjacent joint fusions were more likely for AA patients at both time intervals (all Ps < .05). Patients who received primary AA for posttraumatic indications exhibited higher rates of major reoperations in the short to medium term compared with patients who underwent TAR. Level III: Retrospective cohort study.

Impact of foot modeling on the quantification of the effect of total ankle replacement: A pilot study

BackgroundKinematic and kinetic foot models showed that computing ankle joint angles, moments and power with a one-segment foot modeling approach alters kinematics and tends to overestimate ankle joint power. Nevertheless, gait studies continue to implement one-segment foot models to assess the effect of total ankle replacement. Research questionThe objective of this pilot study was to investigate the effect of the foot modeling approach (one-segment versus multi-segment) on how total ankle replacement is estimated to benefit or degrade the patient’s biomechanical performance. MethodsTen subjects with post-traumatic ankle osteoarthritis scheduled for total ankle replacement and 10 asymptomatic subjects were recruited. A one-segment and a multi-segment foot model were used to calculate intrinsic foot joints kinematics and kinetics during gait. A linear mixed model was used to investigate the effect of the foot model on ankle joint kinematic and kinetic analysis and the effect of total ankle replacement. ResultsDifferences in range of motion due to the foot model effect were significant for all the gait subphases of interest except for midstance. Peak power generation was significantly overestimated when computed with the one-segment foot model. Ankle and shank-calcaneus joint dorsi-/plantarflexion range of motion did not increase post-operatively except during the loading response phase. A significant ‘group’ effect was found for stance and pre-swing phase range of motion, with total ankle replacement patients showing lower range of motion values than controls for dorsi/plantarflexion. SignificanceThe outcome of this study showed that the ‘foot model’ had a significant effect on estimates of range of motion and power generation. The findings in our study therefore emphasize the clinical interest of multi-segment foot modeling when assessing the outcome of a therapeutic intervention.

The Demographics of Total Ankle Replacement in the USA: A Study of 21,222 Cases Undergoing Pre- Operative CT Scan-Based Planning

Category:Ankle; Ankle ArthritisIntroduction/Purpose:To understand the role of total ankle replacement (TAR) in treating the spectrum of arthritis of the ankle, a clear understanding of the epidemiology of ankle arthritis is required. The largest pools of epidemiologic data available to date come from international registries. In the USA, the largest market for TAR, where an estimated 10,000 TARs are implanted per year, the largest pool of demographic data on patients undergoing TAR is comprised of just 805 cases collected over 6 years. With the advent of patient-specific instrumentation (PSI), detailed demographic and CT scan data can now be collected. These data on 21,222 cases undergoing CT scan-based PSI planning were reviewed to define the demographics of a very large cohort of TAR patients.Methods:The cohort contained 21,222 patients from the USA and Canada, with surgery dates from 2012 - 2019. Data analysed included deformity measures, presence of existing hardware and joint fusion status. To date, a subset sample of 4800 cases was available for analysis. Extraction is ongoing and data for the full cohort will soon be available. This subset described cases with surgery dates ranging from November 2015 through May 2019. Summary statistics to describe age, gender, ankle size, and tibio- talar deformity were calculated.Of the 4800 patients analyzed, 53% were male. Mean age 63.6 years (SD 10.4) (Age distribution in Figure 1a). The deformity distribution is shown in Figure 1b, with varus more common than valgus. The mean degree of deformity increased with every decade of patient age from 6.1° (age 30-39) to 9.2° (age 80-89), and over time from 9.3°(2016) to 11.8° (2019) [in stemmed- implant cases].Results:Tibia size varied with gender. Females ranged between 34-38mm in 85% of cases; males from 41-48mm in 79%. Of 21,222 cases, 5964 (28%) had adjacent hardware (screws, etc) in situ and pre-existing ankle fusions were present in 517 (2.4%), increasing from 1.2% in 2013 to 2.9% in 2019.The mean age of TAR patients is similar to that reported in smaller series. Tibia size was significantly greater in males than females, a finding not previously reported in demographic literature. In contrast to knee arthritis, intra-articular deformity >5° is common, present in > 51% of cases (varus > valgus). This is the first series to show the degree of deformity increases with age. Over time, TAR is being used in cases with greater deformity.Conclusion:Hardware is seen to be commonly present in TAR, increasing complexity. Conversion of fusion to TAR, while rare, is more common than existing literature suggests, with the rate increasing each year, suggesting this may be an increasingly important role for TAR in the future.This study presents the largest set of demographic data on TAR patients in the literature. The demographics of USA patients undergoing TAR are similar to those seen in non-USA registries. Deformity is common, increasing with age. The severity of deformity treated with TAR and conversion of fusion to TAR are increasing over time.