Time trends in total ankle arthroplasty in the USA: a study of the National Inpatient Sample

Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty

Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.

Sex Differences in Patient-Reported Outcomes and Range of Motion After Total Ankle Arthroplasty

BackgroundAs the popularity of total ankle arthroplasty (TAA) increases, there is a growing need to examine the effects of sex on postoperative outcomes. This study compares patient-reported outcome measures and ankle range of motion (ROM) in the postoperative period, as stratified by sex.MethodsPatients who underwent TAA during 2013 to 2018 with a minimum follow-up of 2 years were included (N = 133). American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Visual Analog Scale (VAS), and 12-Item Short-Form Survey (SF-12) were administered preoperatively and at 6 months, 1 year, and 2 years postoperatively. ROM was recorded at these same time points.ResultsPreoperatively and at 6 months postoperatively, the cohorts did not differ in any of the measured outcomes. At 1 year postoperatively, females had lower SF-12 Physical Composite Scores (female = 44.1, male = 47.1, P = .019) and less plantarflexion (female = 20.5 degrees, male = 23.5 degrees, P = .029). By 2 years postoperative, females had lower AOFAS scores (female = 80.3, male = 85.4, P = .040). A greater complication rate amongst the female cohort approached significance at 18.6% versus 9% for males (P = .124).DiscussionThese results support TAA as a reliable means of treating ankle arthritis in both sexes, despite important differences. Understanding these outcome differences is critical for effectively managing expectations and treating both female and male populations.Levels of Evidence:Level III: Retrospective cohort study.

Increasing utilization of total ankle arthroplasty in Japan: Trends and regional variations over 12 Years from a national database

BACKGROUND

Ankle arthritis significantly impacts a patient's quality of life, often necessitating surgical treatment in advanced cases. While ankle arthrodesis has been the standard procedure for decades, total ankle arthroplasty (TAA) has gained acceptance as a motion-preserving alternative. Although TAA adoption has expanded globally, data on trends and regional variations in Japan are limited. This study aimed to analyze the utilization and regional disparities in TAA and ankle arthrodesis over a 12-year period using a national database.

METHODS

Data were retrospectively extracted from the Diagnosis Procedure Combination database, which includes over 50 % of inpatient admissions in Japan. Patients who underwent primary TAA or ankle arthrodesis for osteoarthritis or rheumatoid arthritis between 2010 and 2022 were included. Procedure counts, patient demographics, and regional variations were analyzed. Statistical methods included linear regression for trend analyses and exploration of factors influencing regional disparities, such as hospital volume and the number of members of the Japanese Society for Surgery of the Foot.

RESULTS

From 2010 to 2022, 2461 TAA and 9415 ankle arthrodesis procedures were performed. TAA utilization increased 3.8-fold compared with a 1.4-fold increase in ankle arthrodesis. The proportion of TAA among ankle surgeries increased from 13.4 % to 30.2 %. TAA was performed more frequently in older patients and those with rheumatoid arthritis than ankle arthrodesis. Over the study period, the average age of TAA patients significantly increased, whereas the proportion of patients with rheumatoid arthritis decreased, reflecting a shift toward treating patients with osteoarthritis. Significant regional variations in TAA utilization were observed, primarily influenced by the availability of high-volume hospitals.

CONCLUSIONS

TAA utilization has grown significantly in Japan, underscoring its acceptance as an alternative to ankle arthrodesis. However, access disparities persist, driven by the limited availability of high-volume hospitals. These findings highlight the need for improved access to TAA and the standardization of surgical practices to ensure equal treatment opportunities for patients with ankle arthritis.

Comparison of PROMIS scores after total hip and total ankle arthroplasty : a propensity score-matched study

Aims

This study evaluated joint-specific and generic patient-reported outcome measures (PROMs) after total hip arthroplasty (THA) and total ankle arthroplasty (TAA) in matched cohorts, while evaluating implant survivorship and 90-day hospital use.

Methods

Primary THA and TAA patients from 1 January 2015 to 1 January 2023 with minimum one-year follow-up were retrospectively reviewed. After applying exclusion criteria, 2,092 THAs and 478 TAAs were analyzed. Demographics, pre- and postoperative PROMs, revision surgeries, emergency department visits, and readmissions were collected. THA and TAA patients were then propensity score matched at a 2:1 ratio for age, sex, race, BMI, American Society of Anesthesiologists classification, and comorbidities, resulting in a final cohort of 844 THAs and 455 TAAs for comparison.

Results

Median preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores between THA and TAA were calculated (66.0 (IQR 62.0 to 70.0) vs 65.0 (IQR 62.0 to 70.0); p = 0.276), and both showed improvement at six weeks. However, THA patients exhibited lower median PROMIS PI scores at one year (53.0 vs 54.0; p = 0.009), as well as a greater median decrease in PROMIS PI from preoperative to one year (-13.0 (IQR -20.0 to -8.0) vs -12.0 (IQR -18.0 to -7.0); p = 0.023). Median preoperative PROMIS physical function (PF) was worse in THA patients (36.0 (IQR 32.0 to 40.0) vs 37.0 (IQR 33.0 to 40.0); p = 0.031), but showed greater median improvement compared to TAA patients at both six weeks (7.0 (IQR 3.0 to 12.0) vs 3.0 (IQR -2.0 to 9.0); p < 0.001) and one year (11.0 (IQR 6.0 to 17.0) vs 8.0 (IQR 4.5 to 13.0); p < 0.001). Preoperative PROMIS depression scores were similar and improved similarly in both groups. Joint-specific PROMs improved in both cohorts.

Conclusion

Patients undergoing THA or TAA experienced improvements in joint-specific PROMs postoperatively which translated to improved generic PROMs across both joints. Generic PROMs can be a useful tool to compare outcomes in THA and TAA. Results suggest that higher functional scores may be achieved sooner in THA.

Complication Rates and Functional Outcomes After Total Ankle Arthroplasty in Patients with Rheumatoid Arthritis

BACKGROUND

For patients with rheumatoid arthritis (RA) undergoing total ankle arthroplasty (TAA), conflicting data have been reported regarding complications and patient-reported outcome (PRO) improvement when compared with patients with osteoarthritis (OA). The purpose of this study was to compare complication rates and PROs among patients with RA, primary OA, or posttraumatic arthritis.

METHODS

This was a retrospective study of 1,071 primary TAAs performed at a single institution between March 2000 and October 2020. Minimum follow-up was 2 years. Patients were stratified by indication for TAA (OA, n = 372; posttraumatic arthritis, n = 642; RA, n = 57). Patient demographics, intraoperative variables, postoperative complications, and PRO measures were compared among the groups using univariable statistics. Cox regression was performed to assess the risk of implant failure. The overall cohort had a mean age of 63.4 years, 51.3% were male, and 94.8% were White. The mean duration of follow-up (and standard deviation) was 5.7 ± 3.1 years.

RESULTS

Compared with the OA and posttraumatic arthritis groups, the RA cohort had the lowest mean age (p < 0.001), lowest percentage of males (p < 0.001), and highest American Society of Anesthesiologists (ASA) score (p < 0.001). Univariable analysis showed no significant difference in the infection rate among the groups (p = 1.0). The RA cohort had the highest rate of heterotopic ossification postoperatively (2 of 57, 3.5%; p < 0.040). Cox regression analysis showed no increased risk of implant failure for the RA cohort (p = 0.08 versus the OA cohort, 0.14 versus the posttraumatic arthritis cohort). For the Short Musculoskeletal Function Assessment (SMFA), Short Form (SF)-36, Foot and Ankle Outcome Score (FAOS)-symptoms subscale, and FAOS-activities of daily living subscale, the RA group reported significantly worse scores in the postoperative period (p < 0.001). However, the RA cohort demonstrated improvements in all PROs.

CONCLUSIONS

In the largest single-institution study to date, patients with RA reported poorer PRO scores compared with the OA and posttraumatic arthritis groups but experienced functional outcome improvement from the preoperative baseline.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Salto Mobile-Bearing Total Ankle Arthroplasty: Survivorship, Radiologic, and Clinical Outcomes at an Average 9-Year Follow-Up

BACKGROUND

Total ankle arthroplasty (TAA) remains an excellent treatment option for end-stage ankle osteoarthritis. Questions remain regarding the superiority of either fixed- or mobile-bearing implants because of equipoise in the literature and a paucity of long-term follow-up. We present results of the Salto mobile-bearing TAA, aiming to add to the literature for longer-term follow-up of this mobile-bearing TAA and investigate the survivorship and patient satisfaction with this implant.

METHODS

TAA was performed in 91 consecutive ankles (87 patients) in an independent, prospective, single-surgeon study. The minimum follow-up was set at 5 years. Implant survival, patient-reported outcome measures (PROMs), and radiographic outcomes are presented at a mean of 9.1 years (range 5-18 years).

RESULTS

Nine ankles (9 patients) were lost to follow-up or were unable to comply. Eighty-two ankles (78 patients) were included with a mean age of 69.5 years at the time of their operation. Six of 82 ankles (7.3%) underwent revision of any of the components. Four were revisions involving the metallic components to fusion or revision TAA, all within 5 years of the index procedure. Three ankles (3.7%) underwent reoperations. With all-cause revision of any component (including the polyethylene liner) as an endpoint, implant survival was calculated using Kaplan-Meier curves as 95.0% at 5 years and 93.2% at 10 years. Reported PROMs were very high and we found no progressive linear lucencies, cysts, or subsidence in TAAs other than in those that underwent revision or reoperation.

CONCLUSION

Our study of 82 Salto mobile-bearing TAAs found commendable survivorship, along with robust radiographic and patient-reported outcomes at an average of 9 years, with survivorship rates comparable to those reported for fixed-bearing implants.

Projections and Epidemiology of Total Ankle and Revision Total Ankle Arthroplasty in the United States to 2030

Background: Total ankle arthroplasty (TAA) utilization is increasing in the United States. As the incidence of this procedure grows, it is important for providers to understand the future projections for ankle arthroplasty and more importantly revision total ankle arthroplasty (rTAA). Methods: The National Inpatient Sample (USA) was queried from 2005 to 2017 for all TAA and rTAA. Poisson and linear regression analysis was performed to project annual incidence of TAA and rTAA to 2030, with subgroup analyses on septic rTAA. Results: There were 5315 TAAs performed in 2017, a 564% (P < .001) increase when compared with the TAAs performed in 2005. From 2017 to 2030, the incidence of TAAs is projected to increase from 110% to 796% (P < .001). There were 1170 rTAAs performed in 2017, a 155% (P < .001) increase when compared with rTAAs performed in 2005. There was a 256% increase in the incidence of septic rTAAs from 2005 to 2017 with a projected increase between 22% and 120% by 2030. Conclusions: The incidence of both TAAs and rTAAs is projected to significantly increase over the next decade. Given the known risk factors of TAA and rTAA, these findings reinforce the need for thoughtful consideration when selecting patients for TAA.

Anemia Severity and the Risks of Postoperative Complications Following Total Ankle Arthroplasty

BACKGROUND

Although studies have demonstrated the effect of anemia severity on postoperative complications after arthroplasties of the shoulder, hip, and knee, no studies have investigated the effect on total ankle arthroplasty (TAA). The objective was to determine the influence of preoperative anemia severity on complications following TAA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2006 to 2019 for patients undergoing TAA. Utilizing the World Health Organization (WHO) definitions of anemia, patients were stratified into 3 cohorts: nonanemia (hematocrit >36% for women, >39% for men), mild anemia (hematocrit 33%-36% for women, 33%-39% for men), and moderate to severe anemia (hematocrit <33% for both women and men). Demographics, comorbidities, length of stay, and short-term (30-day) postoperative complications were compared between groups. Bivariate analyses, including χ2 and analysis of variance, and multivariable logistical regression were performed.

RESULTS

After exclusion, 1490 patients (1313 nonanemia [88.1%], 154 mild anemia [10.3%], and 23 moderate/severe anemia [1.6%]) were included. Increasing severity of anemia was associated with an increased average hospital length of stay (1.84 vs 2.19 vs 2.78 days, P < .001) and rate of reoperation (0.38% vs 3.90% vs 4.35%, P < .001). There was a statistically significant increase in wound disruptions (0.15% vs 1.95% vs 4.35%, P = .001), minor complications (1.52% vs 4.55% vs 8.70%, P = .008), major complications (1.98% vs 5.84% vs 4.35%, P < .033), and any complications (3.50% vs 10.39% vs 13.04%, P = .001) between groups. Multivariate analysis identified mild and moderate/severe anemia as a predictor of reoperation and extended length of stay (P ≤ .033).

DISCUSSION

Preoperative anemia is a modifiable risk factor for medical and surgical complications within 30 days of TAA. Medical optimization prior to surgical intervention is necessary in patients undergoing TAA.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.

Are There Differences in Patient-Reported Outcomes Measurement Information System Scores After Total Knee and Total Ankle Arthroplasty in Matched Patients?

BACKGROUND

The purpose of this study was to evaluate Patient-Reported Outcomes Measurement Information System (PROMIS) scores, a generic patient-reported outcome measure (PROM), as a tool to compare outcomes between total knee (TKA) and total ankle arthroplasty (TAA).

METHODS

Patients who underwent TKA or TAA from January 1, 2019, to December 31, 2023, with at least 1 year of follow-up, were reviewed retrospectively. Upon application of the criteria, 2,418 TKAs and 500 TAAs were utilized for analysis. Demographics, PROMs, emergency department visits, readmissions, and revision surgeries were collected. Propensity score matching at a 3:1 ratio of TKA to TAA patients was then done, balancing age, sex, race, body mass index, and American Society of Anesthesiologists classification, which resulted in a final cohort of 1,256 TKAs and 470 TAAs.

RESULTS

Preoperative PROMIS pain interference (PI) scores were similar between TKA and TAA, and both showed improvements by 6 weeks. Patients undergoing TAA, however, had a greater decrease in PI scores at 1 year (TKA: -10.0 [-15.0 to -5.0]) versus TAA: -11.0 [-17.0 to -6.0]; P = 0.044). Regarding PROMIS physical function (PF), preoperative scores were also similar for TKA and TAA patients. Additionally, patients in both groups had similar improvement in PF at 1 year; however, TKA patients had better PF at 6 weeks (TKA: 41.0 [36.0 to 46.0] versus TAA: 37.0 [33.0 to 41.0]; P < 0.001). Preoperative PROMIS depression scores were similar between groups and showed similar improvement after surgery. Joint-specific PROMs improved in each cohort, respectively.

CONCLUSIONS

Both TKA and TAA showed improvement postoperatively in joint-specific PROMs, which concurrently resulted in PROMIS score improvement across all domains in both joints. This suggests that arthroplasties across different anatomic sites can be compared using generic PROMs. For TKA and TAA, similar improvements in PROMIS PI, PF, and depression were noted 1 year after surgery.

LEVEL OF EVIDENCE

III.

Obesity is highly associated with a non-home discharge following total ankle arthroplasty

Studies have shown that non-home discharge following orthopedic procedures is associated with a higher risk of 30-day complications and significantly increases medical costs. The purpose of this study was to identify risk factors for being discharged to a non-home destination following total ankle arthroplasty (TAA). We included patients undergoing TAA from the American College of Surgeons National Surgical Quality Improvement Program database (NSQIP) between 2014 and 2019. TAA was identified using CPT codes 27702, 27703 and 27704. Logistic regression models were used to assess the association between discharge location (home versus non-home) and a series of exposure variables (e.g., patient demographics, patient health characteristics, and operative factors). A total of 1,704 patients were included, experiencing a 3.6% short term complication rate (61/1,704). 8.5% of the population were discharged to a non-home destination. In the final adjusted model, patients who were older [OR 1.11; 95%CI 1.08, 1.13], female [OR 2.94; 95%CI 2.04, 4.34], obese [OR 1.93; 95%CI 1.29, 2.89], had surgery in an inpatient setting [OR 5.73; 95%CI 1.78, 18.46], and ASA class IV [OR 10.65; 95%CI 1.03, 110.61] were at greater risk for a non-home discharge. People living with obesity experienced a nearly 2x greater likelihood of being discharged to a non-home destination after TAA despite their preoperative functional (e.g., ASA class) and metabolic status (i.e., diabetes). Opportunities to mitigate this risk will be needed to lessen the financial burden of TAA surgery as a growing number of obese patients become eligible for TAA in the US.

SPECT/CT of Total Ankle Arthroplasty

Use of SPECT/CT (Single Photon Emission Computed Tomography/Computed Tomography) is increasing providing additional information in patients with inconclusive clinical examination and unremarkable imaging findings presenting with chronic pain after total ankle arthroplasty. To differentiate the cause of pain after total ankle arthroplasty can be challenging. SPECT/CT combines structural and metabolic imaging as a hybrid tool leading to higher specificity and overall diagnostic accuracy presumably in cases of gutter impingement, prosthetic loosening, and osteoarthritis of adjacent joints. Moreover, SPECT/CT can complement diagnostic work up in periprosthetic joint infections. Basal tracer enhancement has to be considered for the interpretation of imaging findings.

The INVISION Talar Component in Revision Total Ankle Arthroplasty: Analysis of Early Outcomes

INTRODUCTION

Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component.

METHODS

This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus.

RESULTS

The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively.

CONCLUSIONS

In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

Trends in the use of ankle arthrodesis and total ankle replacements in Australia over the past 20 years

BACKGROUND

End stage ankle osteoarthritis (OA) is debilitating. Surgical management consists of either ankle arthrodesis (AA) or a total ankle replacement (TAR). The purpose of this study is to assess the trends in operative intervention for end stage ankle OA in an Australian population.

METHODS

This is a retrospective epidemiological study of 15,046 surgeries. Data were collected from publicly available national registries including the Australian Medicare Database and Australian Orthopaedic Association National Joint Replacement Registrar from 2001 to 2020.

RESULTS

There was a significant increase in all ankle surgeries performed across the period of interest. AA remained the more commonly performed procedure throughout the course of the study (11,946 cases, 79.4%) and was never surpassed by TAR (3100, 20.6%). The overall proportions demonstrated no significant changes from 2001 to 2020.

CONCLUSION

The incidence of ankle surgeries continues to increase with the ageing and increasingly comorbid population of Australia. Despite demonstrating no significant overall change in the ratio of TAR and AA in our study population and period, there are noticeable trends within the timeframe, with a recent surge favouring TAR in the last 5 years.

Body Mass Index, Sex, and Age Are Predictors of Discharge to a Post-acute Care Facility Following Total Ankle Arthroplasty

BACKGROUND

The utilization of total ankle arthroplasty (TAA) continues to increase. Discharge to a post-acute care (PAC) facility can increase patient morbidity and postoperative costs. The purpose of this study is to investigate the effects of age and body mass index (BMI) on discharge to a PAC facility and hospital length of stay (LOS) following TAA.

METHODS

A retrospective review of patients who underwent TAA from the National Surgical Quality Improvement Program (NSQIP) database was performed. Using overweight patients as the reference BMI group, sex- and age-adjusted log-binomial regression models were utilized to estimate risk ratios of BMI categories for being discharged to a PAC facility. A linear regression was utilized to estimate the effect of BMI category on hospital LOS.

RESULTS

Obese patients had 1.36 times the risk of overweight patients (P = .040), and morbidly obese patients had 2 times risk of overweight patients (P = .001) of being discharged to a PAC facility after TAA. Men had 0.48 times the risk of women (P < .001). Compared with patients aged 18 to 44 years, patients aged ≥65 years had 4.13 times the risk (P = .012) of being discharged to a PAC facility after TAA. Relative to overweight patients, on average there was no difference in hospital LOS for underweight patients, but healthy weight patients stayed an additional 0.30 days (P=.003), obese patients stayed an additional 0.18 days (P = .011), and morbidly obese patients stayed an additional 0.33 days (P = .009). Men stayed 0.29 fewer hospital days than women (P < .001) on average.

CONCLUSION

Women and patients who are obese or morbidly obese have a longer hospital LOS and an increased chance of being discharged to a PAC facility. Increasing age is also associated with an increased risk of being discharged to a PAC. These may be important factors when developing and discussing the postoperative plan with patients prior to TAA.

LEVELS OF EVIDENCE

Level III.

Effect of body mass index on acute postoperative complications following Total Ankle Arthroplasty (TAA)

BACKGROUND

Total ankle arthroplasty (TAA) is an effective treatment for various ankle pathologies, but some concern remains for the high associated complication and failure rates relative to major joint arthroplasty of the hip and knee. Patient body mass index (BMI) is a modifiable and potentially important preoperative variable when evaluating postoperative complications. The purpose of this study is to evaluate the effect of BMI, age and sex on the acute postoperative complication rate after TAA.

METHODS

We retrospectively reviewed adult patients who underwent TAA between 2006 and 2021 from the NSQIP database. Using overweight patients as the reference BMI group, we utilized log-binomial models to estimate risk ratios on outcomes while adjusting for sex and age to investigate whether there were significant adjusted differences in complication rates among the BMI groups.

RESULTS

We found that, relative to overweight patients, there were no statistically significant differences in the risk of acute complications for underweight (BMI < 18.5) (P = .118), healthy weight (18.5≤BMI < 25) (P = .544), obese (30≤BMI < 40) (P = .930), or morbidly obese (BMI < 40) (P = .602) patients who underwent TAA. There were also no statistically significant differences in the risk of acute complications based on age category (P = .482,.824) or sex (P = .440) for TAA. Additionally, there were no significant differences between the BMI groups for either major complications (P = .980) or minor complications (P = .168).

CONCLUSION

Ultimately, we found that BMI, age, and sex did not lead to statistically significant differences in the risk of complications within 30 days postoperatively for TAA, even when stratified by major vs minor complications.

LEVEL OF EVIDENCE

Level III.

Outcomes of Revision Total Ankle Replacement

The objective of this study is to provide an up-to-date review of the outcomes of revision total ankle arthroplasty (TAA). Relevant studies published over the last decade were reviewed. Twelve studies were included. At a median follow-up of 4 years, the median survival and reoperation rates were 86% and 16%, respectively. Significant postoperative improvements in patient-reported outcome measures were recorded in 6 studies. Significant improvement in alignment was documented in 1 study only. Revision TAA is a safe procedure that can produce good outcomes. Nevertheless, data relating to long-term outcome are still limited in quantity and duration.

Younger Patients Undergoing Total Ankle Arthroplasty Experience Higher Complication Rates and Worse Functional Outcomes

BACKGROUND

Although many patients with posttraumatic ankle arthritis are of a younger age, studies evaluating the impact of age on outcomes of primary total ankle arthroplasty (TAA) have revealed heterogenous results. The purpose of the present study was to determine the effect of age on complication rates and patient-reported outcomes after TAA.

METHODS

We retrospectively reviewed the records of 1,115 patients who had undergone primary TAA. The patients were divided into 3 age cohorts: <55 years (n = 196), 55 to 70 years (n = 657), and >70 years (n = 262). Demographic characteristics, intraoperative variables, postoperative complications, and patient-reported outcome measures were compared among groups with use of univariable analyses. Competing-risk regression analysis with adjustment for patient and implant characteristics was performed to assess the risk of implant failure by age group. The mean duration of follow-up was 5.6 years.

RESULTS

Compared with the patients who were 55 to 70 years of age and >70 years of age, those who were <55 years of age had the highest rates of any reoperation (19.9%, 11.7%, and 6.5% for the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001), implant failure (5.6%, 2.9%, and 1.1% for the <55, 55 to 70, and >70-year age groups, respectively; p = 0.019), and polyethylene exchange (7.7%, 4.3%, and 2.3% for the <55, 55 to 70, and >70-year age groups, respectively; p = 0.021). Competing-risk regression revealed a decreased risk of implant failure for patients who were >70 of age compared with those who were <55 years of age (hazard ratio [HR], 0.21 [95% confidence interval (CI), 0.05 to 0.80]; p = 0.023) and for patients who were 55 to 70 years of age compared with those who were <55 years of age (HR, 0.35 [95% CI, 0.16 to 0.77]; p = 0.009). For all subscales of the Foot and Ankle Outcome Score (FAOS) measure except activities of daily living, patients who were <55 years of age reported the lowest (worst) mean preoperative and postoperative scores compared with those who were 55 to 70 years of age and >70 years of age (p ≤ 0.001). Patients who were <55 years of age had the highest mean numerical pain score at the time of the latest follow-up (23.6, 14.4, 12.9 for the <55, 55 to 70, and >70-year age groups, respectively; p < 0.001).

CONCLUSIONS

Studies involving large sample sizes with intermediate to long-term follow-up are critical to reveal age-related impacts on outcomes after TAA. In the present study, which we believe to be the largest single-institution series to date evaluating the effect of age on outcomes after TAA, younger patients had higher rates of complications and implant failure and fared worse on patient-reported outcome measures.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Chronic Steroid Use Does Not Increase the Risk of Superficial Surgical Site Infection or Wound Dehiscence Following Total Ankle Arthroplasty

Introduction Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis. Recent surgical and technological advances have led to a significant increase in the surgical volume of TAA. While a majority of ankle arthritis is post-traumatic in nature, other causes include autoimmune or inflammatory conditions. Medical management of these conditions frequently requires chronic corticosteroid administration, which is a well-established risk factor for complications following surgery. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TAA. Methods The American College of Surgeons National Surgical Quality Improvement (NSQIP) database was analyzed to identify all patients who underwent TAA between 2015 and 2020. Patient characteristics including demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. The data was analyzed using bivariate and multivariate logistic regression to identify all postoperative complications associated with chronic preoperative steroid use. Results A total of 1,606 patients were included in this study: 1,533 (95.5%) were included in the non-steroid cohort, and 73 (4.5%) were included in the chronic steroid cohort. Chronic steroid use was significantly associated with female sex (p < 0.001) and American Society of Anesthesiologists (ASA) ≥3 (p < 0.001). Chronic steroid use was not associated with superficial surgical site infection (SSI) (p = 0.634) or wound dehiscence (p = 0.999). The postoperative complication that was significantly associated with chronic steroid use was sepsis (p = 0.031). After adjusting for female sex and the ASA grade, chronic steroid use was found to be independently associated with sepsis (p = 0.013). Conclusion Preoperative chronic steroid use is not associated with superficial SSI or wound dehiscence within 30 days following TAA. As TAA becomes a more attractive alternative to ankle arthrodesis, a better understanding of preoperative risk factors can aid in widening indications and knowing what patients are at risk for complications.

Survival and risk assessment in revision arthroplasty of the ankle

Aims

Implant failure has become more common as the number of primary total ankle arthroplasties (TAAs) performed has increased. Although revision arthroplasty has gained attention for functional preservation, the long-term results remain unclear. This study aimed to assess the long-term outcomes of revision TAA using a mobile-bearing prosthesis in a considerably large cohort; the risk factors for failure were also determined.

Methods

This single-centre retrospective cohort study included 116 patients (117 ankles) who underwent revision TAA for failed primary TAA between July 2000 and March 2010. Survival analysis and risk factor assessment were performed, and clinical performance and patient satisfaction were evaluated preoperatively and at last follow-up.

Results

The mean duration from initial revision TAA to last follow-up was 15.0 years (SD 3.0; 11.2 to 20.5). The cumulative survival rates of the revised ankles were 81% (95% confidence interval (CI) 74% to 88%), 74% (65% to 82%), and 70% (61% to 79%) at five, ten, and 15 years, respectively. Comorbidities prior to primary TAA, aseptic loosening, instability, or grafting of cysts were found to be the most common risk factors for secondary revision. The median value for preoperative pain, as assessed using the visual analogue scale, declined from 6 (interquartile range (IQR) 5 to 8) to 2 (IQR 0 to 5) (p < 0.001) and the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot score improved from 43 (SD 17) preoperatively to 70 (SD 20) (p < 0.001) at last follow-up.

Conclusion

Revision TAA offers acceptable survival rates after 15 years; it therefore offers a valuable option for treatment of implant failure in carefully selected cases. Although patient-reported outcomes improve substantially, the degree of improvement reported following primary TAA is not achieved.

Ankle and subtalar joint axes of rotation and center of rotation during walking and running in healthy individuals measured using dynamic biplane radiography

The goal of this study was to determine how foot type and activity level affect ankle and hindfoot motion. Dynamic biplane radiography and a validated volumetric registration process was used to measure ankle and hindfoot motion of 20 healthy adults during walking and running. The helical axes of motion (HAM) during stance were calculated at the tibiotalar and subtalar joints. The intersection of each HAM and the rotation plane of interest defined the tibiotalar and subtalar centers of rotation (COR). Correlations between foot type and hindfoot kinematics were calculated using Pearson's correlations. The effect of activity, phase of gait, and dominant vs. non-dominant limb on HAM and COR were evaluated using linear mixed effects models. Activity and phase of gait influenced the superior location of the tibiotalar (p < 0.041) and subtalar (p < 0.044) CORs. Activity and gait phase affected tibiotalar (p < 0.049) and subtalar (p < 0.044) HAM direction during gait. Both HAM orientation and COR location changed with activity and phase of gait. These ankle and hindfoot kinematics have implications for total ankle replacement design and musculoskeletal models that estimate force and moment generating capabilities of muscles.

Racial, Socioeconomic, and Payer Status Disparities in Utilization of Total Ankle Arthroplasty Compared to Ankle Arthrodesis

Total ankle arthroplasty is increasingly being used for the treatment of ankle osteoarthritis when compared to arthrodesis. However, there has been limited investigation into disparities in utilization of these comparable procedures. This study examined racial/ethnic, socioeconomic, and payer status disparities in the likelihood of undergoing total ankle arthroplasty compared with ankle arthrodesis. Patients with a diagnosis of ankle osteoarthritis from 2006 through 2019 were identified in the National Inpatient Sample, then subclassified as undergoing total ankle arthroplasty or arthrodesis. Multivariable logistic regression models, adjusted for hospital location, primary or secondary osteoarthritis diagnosis, and patient characteristics (age, sex, infection, and Elixhauser comorbidities), were used to examine the effect of race/ethnicity, socioeconomic status, and payer status on the likelihood of undergoing total ankle arthroplasty versus arthrodesis. Black and Asian patients were 34% and 41% less likely than White patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Patients in income quartiles 3 and 4 were 22% and 32% more likely, respectively, than patients in quartile 1 to undergo total ankle arthroplasty rather than arthrodesis (p = .001 and p = .01, respectively). In patients <65 years of age, privately insured and Medicare patients were 84% and 37% more likely, respectively, than Medicaid patients to undergo total ankle arthroplasty rather than arthrodesis (p < .001). Racial/ethnic, socioeconomic, and payer status disparities exist in the likelihood of undergoing total ankle arthroplasty versus arthrodesis for ankle osteoarthritis. More work is needed to establish drivers of these disparities and identify targets for intervention, including improvements in parity in relative procedure utilization.

SPECT/CT of Total Ankle Arthroplasty

Use of SPECT/CT (Single Photon Emission Computed Tomography/Computed Tomography) is increasing providing additional information in patients with inconclusive clinical examination and unremarkable imaging findings presenting with chronic pain after total ankle arthroplasty. To differentiate the cause of pain after total ankle arthroplasty can be challenging. SPECT/CT combines structural and metabolic imaging as a hybrid tool leading to higher specificity and overall diagnostic accuracy presumably in cases of gutter impingement, prosthetic loosening, and osteoarthritis of adjacent joints. Moreover, SPECT/CT can complement diagnostic work up in periprosthetic joint infections. Basal tracer enhancement has to be considered for the interpretation of imaging findings.

Analysis of Baseline Characteristics, Length of Stay, Cost of Care, Complications and Subgroup Analysis of Patients Undergoing Total Ankle Arthroplasty-A Large Database Study

Although total ankle arthroplasty (TAA) is becoming a progressively common procedure with a reported 10-fold increase in its prevalence over the past 2 decades; there is still limited large-scale data regarding its overall outcome. Using the National Inpatient Sample (NIS) database, patients who underwent TAA between 2016 and 2019 were identified (ICD-10 CMP code). Data regarding demographic details, co-morbidities, geographic locations of procedure, hospital stay, expenditure incurred, and complications encountered were analyzed. Additionally, a comprehensive subgroup analysis was performed to evaluate the impact of multiple preoperative variables (including gender, diabetes, obesity, CKD and tobacco abuse) on the patient outcome. Overall, 5087 patients (mean age: 65.1 years, 54% males, 85% Caucasians, 75% from large metropolitan regions) underwent TAA. Eighty eight percent of patients were discharged to home; and the mean length of hospital stay and hospital-related expenditure were 1.7 ± 1.41 days and $92,304.5 ± 50,794.1, respectively. The overall complication rate was 8.39% {commonest medical complications: anemia [131 (2.6%) patients) and acute renal failure [37 (0.7%) patients]; commonest local complication: periprosthetic mechanical adversities [90 (1.7%) patients]}. Female and CKD patients demonstrated significantly higher risks of medical (female: p = .003; CKD: p < .001) and surgical (female: p = .005; CKD: p < .019) complications; while obesity substantially enhanced the risk of medical adversities (p < .001). Based on our study, we could conclude that the rates of TAA in the United States are on the rise, especially in regions with population greater than 250,000. TAA is a safe procedure with relatively low complication rates. The complications and hospital-associated expenditure seem to vary between different patient subgroups.

Readability and quality of online information on total ankle arthroplasty

The internet is a frequently utilized resource to acquire health information. This study aims to examine the readability and quality of online information pertaining to total ankle arthroplasty (TAA). "Ankle arthroplasty" OR "ankle replacement" was queried in three search engines, with the first 3 pages of results identified. The readability of sites was calculated using six readability algorithms: Flesch-Kincaid grade level, Flesch Reading Ease, Gunning Fog, SMOG, Coleman-Liau index, and Automated Readability Index. Quality was assessed using the JAMA benchmark, Global Quality Score (GQS), and DISCERN instrument. A total of 62 relevant sites were analyzed. Sources were primarily physician-sponsored (50%) or academic (31%) websites. The mean readability indices were above the recommended sixth grade reading level, with an average grade level of across scoring tools of 13.22 ± 2.07. No sites were at or below a sixth grade reading level. Quality ratings were subpar across assessment tools: JAMA = 1.9 ± 1.0 (range, 1-4) out of 4; GQS = 3.4 ± 1.0 (range, 1-5) out of 5. DISCERN = 54.0 ± 11.2 (range, 31-75) out of 80. The readability and quality of online information regarding ankle arthroplasty is not optimal for the average patient, with improvement valuable in cultivating shared decision-making.

Clinical Outcomes of Total Knee Arthroplasty With Concomitant Total Ankle Arthroplasty Versus Ankle Arthrodesis

Prior studies have demonstrated a high incidence of ankle osteoarthritis (OA) in patients undergoing total knee arthroplasty (TKA) as well as inferior outcomes in the setting of ankle OA or hindfoot malalignment. Little is known about the effect of the 2 most common surgical treatments for ankle OA, ankle arthrodesis and total ankle arthroplasty (TAA) on TKA. This hypothesis is that the preservation of ankle motion afforded by total ankle arthroplasty may reduce pathologic stresses across the knee joint. This study compares outcomes of patients who underwent both TKA and TAA versus those that underwent TKA and ankle arthrodesis. We retrospectively reviewed a cohort of patients who had undergone TKA and either TAA or ankle arthrodesis at this institution, examining knee injury and OA outcome scores, foot and ankle ability measure scores, revision surgery, knee range of motion, and pain. There were 69 eligible subjects, 13 who had undergone total knee arthroplasty and total ankle arthroplasty and 56 who had undergone TKA and ankle arthrodesis. No significant differences were observed in KOOS Jr scores, FAAM scores, incidence of revision, knee range of motion, or pain at final follow up (p > .05). Mean follow-up time was 46 months after both surgeries were completed. Equivalent outcomes were observed between the 2 groups. The presence of a TKA should not alter the indications for treatment of ankle OA with TAA versus arthrodesis. Further studies are needed as these relatively rare concomitant procedures are likely to become more common in the future.

Analysis of Polyethylene-Related Revisions After Total Ankle Replacements Reported in US Food and Drug Administration Medical Device Adverse Event Database

BACKGROUND

There are 2 general types of total ankle replacement (TAR) designs with respect to the polyethylene insert, mobile-bearing (MB) and fixed-bearing (FB) TARs. The aim of this study is to compare polyethylene-related adverse events (AEs), particularly revisions, reported for MB TARs and FB TARs using the US Food and Drug Administration's (FDA's) Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

A text mining method was applied to the medical device reporting (MDR) in the MAUDE database from 1991 to 2020, followed by manual reviews to identify, characterize, and describe all polyethylene-related AEs, including revisions, reported for MB and FB TARs.

RESULTS

We found 1841 MDRs for MB (STAR Ankle only) and 1273 MDRs for 40+ FB TARs approved/cleared by the FDA. For the MB design, 33% (606/1841) of the AEs reported related to the polyethylene component, compared to 24% (291/1273) of the AEs reported for FB designs. Polyethylene fractures were reported in 11.3% (208/1841) for the MB designs compared to 0.2% (2/1273) for the FB designs. Half of the polyethylene-related revisions occurred within an average of 4.1 years after implantation for the MB design compared within an average of 5.2 years for FB designs.

CONCLUSION

Analysis of this database revealed a higher proportion of reported polyethylene fractures and greater need for earlier revisions for polyethylene-related issues with use of the primary MB design in the database as compared with FB TAR designs. Further study of device-related complications with more recent designs for both MB and FB ankle replacement components are needed to improve the outcomes of total ankle replacement.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Intermediate to long-term clinical outcomes and survival analysis of the Salto Mobile Bearing total ankle prothesis

INTRODUCTION

Osteoarthritis of the ankle is a major burden to affected patients. While tibio-talar arthrodesis has been the gold-standard regarding the treatment of osteoarthritis of the ankle joint for many years, at present total ankle arthroplasty (TAA) provides appealing clinical outcomes and is continually gaining popularity. The aim of this study was to evaluate the intermediate- to long-term clinical outcome including the survival rate of Salto Mobile Bearing TAA (Tonier SA, Saint Ismier, France).

MATERIAL AND METHODS

In this retrospective study intermediate- to long-term outcomes measures [Ankle Range of Motion (ROM), American Orthopaedic Foot and Ankle Score (AOFAS score) and survival rate] of 171 consecutive TAA were analysed and compared before and after surgery. Revision was defined as secondary surgery with prothesis component removal, while reoperation was defined as a non-revisional secondary surgery involving the ankle.

RESULTS

At a mean follow-up (FU) period of 7.2 ± 2.7 years (range 2.0 to 14.1 years) there was a significant improvement in ankle ROM (total ROM improved from 25.0° ± 15.0° to 28.7° ± 11.3°, p = 0.015; plantarflexion improved from 18.4° ± 11.7° to 20.6° ± 8.2°, p = 0.044; dorsiflexion improved from 6.6° ± 5.7° to 8.1° ± 4.9°, p = 0.011). AOFAS score increased significantly by 41 ± 15 points after surgery (43.3 ± 11.1 before and 84.3 ± 12.0 after surgery, p < 0.001). Overall survival rate within the FU was 81.3% (95% CI 75.3% to 87.3%) with any secondary surgery, 89.9% (95% CI 84.1% to 93.6%) with revision and 93.6% (95% CI 89.8% to 97.3%) with reoperation as endpoint.

CONCLUSION

This study endorses the previously reported appealing intermediate- to long-term outcomes of the Salto Mobile Bearing TAA. There was a significant increase in ROM and AOFAS score as well as decent implant survival at final FU.

The Impact of Hospital Size and Teaching Status on Outcomes Following Total Ankle Arthroplasty

The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models.

Consumer Interest in Total Ankle Replacements Over the Last 10 Years: A Google Trends™ Analysis From 2009 to 2019

With an aging population, the incidence of osteoarthritis (OA) continues to grow. After exhausting conservative therapy for many forms of OA, patients regularly opt for surgical intervention in the form of total joint replacement surgery. One form, total ankle replacement, has continued to gain favorability in the medical community. Improved implant design and surgical technique have enabled success rates of total ankle replacements to approach those of the hip and knee. As a new and improving therapy to address end-stage ankle OA, knowledge of patient-interest has yet to be determined. We used search inquiry data for the keywords "ankle arthritis" "ankle replacement" and "ankle fusion" available from Google Trends™ to identify trends in patient and geographic interest from 2009 to 2019. Search inquiries significantly increased for all keywords over time (p < .001). Trend analysis over this 10-year period revealed a strong correlation for ankle arthritis (0.88) and ankle replacement (0.76). Moreover, the correlation between "ankle arthritis" and "ankle replacement" was strong (0.83) during this period. The geographic distribution of these search terms showed the greatest increase in interest for the keywords "ankle arthritis" "ankle replacement" and "ankle fusion" in Arizona, New York, and Virginia respectively. Results of this study illustrate a similar increasing patient interest in ankle arthritis and ankle replacements. This data can be used effectively identify, educate, and treat populations interested in ankle replacements. To the best of our knowledge, this is the first study to utilize Google Trends™ to analyze patient interest in foot and ankle surgery.

Economic impact of Comorbidities in Total Ankle Arthroplasty and Ankle Arthrodesis

BACKGROUND

The demand for total ankle arthroplasty (TAA) and ankle arthrodesis surgery is increasing. Findings from other orthopaedic populations suggest an increasing comorbidity burden among those planned for surgery, however, data on TAA and ankle arthrodesis is limited. The goal of this study is to study the comorbidity burden for TAA and ankle arthrodesis.

HYPOTHESIS

Comorbidity burden is associated with higher resource utilization for both TAA and ankle arthrodesis.

PATIENTS AND METHODS

This retrospective cohort study utilized data from the nationwide Premier Healthcare Database (2006-2016) which contains inpatient claims on n=10,085 ankle arthrodesis and n=4,977 TAA procedures. Patients were categorized into Deyo-Charlson comorbidity index (DCCI) groups. Outcomes were cost of hospitalization, length of stay (LOS), total opioid utilization, discharge to a skilled nursing facility (SNF), and 30-day readmission. Mixed-effects models estimated associations between DCCI and outcomes. We report odds ratios (OR, or % change for continuous outcomes) and 95% confidence intervals (CI).

RESULTS

In the TAA group, 67.9% of patients were in DCCI category 0 while 22.4%, 6.6%, and 3.1% were in the 1, 2, and >2 DCCI categories, respectively. This was 61.3%, 18.1%, 9.8% and 10.9% in the ankle arthrodesis group. The most common comorbidities were obesity, diabetes mellitus, and chronic pulmonary disease. Particularly in the ankle arthrodesis group, the proportion of patients with comorbidities has increased over time. After adjustment for relevant covariates, patients in the DCCI group >2 (compared to '0') were associated with stepwise effects of up to 77.1% (CI 70.9%; 83.6%) longer length of stay and up to 48.5% (CI 44.0%; 53.2%) higher cost of hospitalization.

DISCUSSIONS

Comorbidity burden is increasing among patients undergoing ankle arthrodesis where it is associated with significantly increased resource utilization. Our data demonstrate the potential impact of patient selection, which may be crucial in optimizing preoperative status.

LEVEL OF EVIDENCE

III.

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

BACKGROUND

Ankle arthrodesis has been the mainstay treatment for end-stage ankle arthritis. The popularity of total ankle arthroplasty (TAA) has been on the rise due to improved implant design and postoperative outcomes. The purpose of this study was to describe the basic epidemiology and trends of annual procedure volumes and incidence in the general American population as well as in different population subgroups from 2009 to 2019. We hypothesize that the incidence of TAA has significantly risen while the median length of hospital stay has decreased nationwide.

METHODS

The IBM MarketScan database was queried for patients who underwent TAA from January 2009 to December 2019 based on Current Procedural Terminology coding. Population estimates from the US Census Bureau were used to calculate the annual incidence of TAA. Procedural volume and incidence were calculated for annual sums, gender, age subgroups, inpatient and outpatient TAA, as well as in four statistical geographic regions in the United States. Median length of hospital stay was calculated and trended annually for inpatient TAA.

RESULTS

A total of 41,060 primary TAAs were identified in the database from 2009 to 2019, in which 52.5% were performed in males. Annual volumes increased by 136.1%, from 2180 to 5147 procedures nationwide. Incidence reported per 100 000 population increased by 120.8%. Both inpatient and outpatient procedures have increased, by 242.5% and 86.6%, respectively. Median length of hospital stay decreased from 3 days in 2009 to 1 day in 2019 and did not differ between genders. Growth in incidence was demonstrated in males and females above the age of 54 years with the largest growth in annual incidence found between 65 and 74 years. Incidence rose in the South and West of the United States by 111.8% and 136.5%, respectively.

CONCLUSION

We found that annual volumes and incidence rates of primary TAA has increased between 2009 and 2019. Although both inpatient and outpatient surgery have become more frequent, inpatient volumes and incidence have increased almost 3 times more than those of outpatient surgery. Length of hospital stay decreased over the study years. When adjusted for the same study period, the cumulative annual growth rates of TAA were found to be 2 times greater than total knee arthroplasty and 3.6 times greater than total hip arthroplasty.

LEVEL OF EVIDENCE

Level III, retrospective database review.

Failure rates and patient-reported outcomes of revision of total ankle arthroplasty

INTRODUCTION

Despite the increasing number of revision total ankle arthroplasty (TAA), the literature on indications, surgical options, and outcomes is limited. This study reports on failure rates and patient-reported outcomes (PROM) for a cohort of 122 patients who underwent revision of TAA.

MATERIALS AND METHODS

A retrospective review of revision TAA between 2006 and 2020 was performed at one institution. Patient's demographics and different surgical procedures were analyzed with particular attention to comparing polyethylene exchange with revision of both metallic components and to additional interventions for axis correction. Failure rates and the European Foot and Ankle Society (EFAS) score were collected. The average follow-up period was 70.37 ± 46.76 months.

RESULTS

122 patients were treated with an exchange procedure. The surgery included 69 polyethylene exchanges, 12 revisions of one metallic component, and 41 revisions of both metallic components. The overall failure rate was 14.75%. The EFAS score, completed by 94 of the 122 patients, was used to evaluate clinical outcomes. Median EFAS score was 12.51 ± 5.53, and median EFAS sports score was 2.97 ± 3.04. Revision rates after polyethylene exchange were significantly higher than after exchanging both metallic components (p value = 0.03), while the EFAS score showed slightly better results in patients treated with polyethylene exchange. Adding procedures to induce axis correction led to significantly lower revision rates (p value = 0.03), and the EFAS score was also improved but without statistical significance.

CONCLUSIONS

The high failure rate of polyethylene exchange indicates that the intervention does not address the actual cause of failed TAA in many cases. Additional axis correction should be considered more frequently. If the underlying issues of prosthesis failure can be identified and sufficiently addressed, the results of revision surgery are likely to improve.

Tranexamic Acid Utilization in Foot and Ankle Surgery: A Meta-analysis

BACKGROUND

Tranexamic acid (TXA) has been widely used in various orthopaedic subspecialities to decrease blood loss, transfusions, and wound complications. However, the role of TXA in foot and ankle surgery is not clearly delineated. This meta-analysis aims to report the efficacy and safety of TXA in relation to foot and ankle surgical procedures.

METHODS

Database searches were conducted for eligible studies from data inception through January 2022. Clinical studies on the use of TXA in foot and ankle procedures reporting the desired outcomes were included. Outcomes were estimated blood loss, change in hemoglobin, and overall complications. Risk of bias was assessed using the Newcastle-Ottawa quality assessment scale and the Joanna Briggs Institute (JBI) critical appraisal tool.

RESULTS

Nine studies met the inclusion criteria. A total of 752 foot and ankle procedures were included, in which 511 (67.95%) procedures received TXA whereas 241 (32.05%) served as controls and did not receive TXA. The pooled data of change in hemoglobin and overall complications showed no difference between the TXA and control group. Estimated blood loss was significantly lower in the patients who received TXA.

CONCLUSION

In conclusion, TXA use was associated with lower estimated blood loss in foot and ankle surgeries without increased risk of thromboembolic events, wound complications, or changes in hemoglobin.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) is a popular modality to treat end-stage arthritis or internal ankle derangement. Unfortunately, failure rates remain undesirably high, with severe complications, including prosthesis failure, ankle fusion, and amputation. The importance of a stable soft-tissue envelope for coverage of implant compromise has been previously described, but the predictive factors for successful salvage of complicated TAA remain poorly understood.

METHODS

A retrospective review was conducted of patients requiring soft-tissue reconstruction following TAA wound complications. Patient demographics, history, microbiological data, reconstructive approach, and outcomes data were collected. Statistical analysis was used to abstract factors associated with unsuccessful prosthetic salvage.

RESULTS

In all, 13 patients met inclusion criteria: 8 (61.5%) achieved prosthetic salvage, and 5 (38.5%) failed. The majority (90.9%) of patients presented with infected joints. Reconstructive techniques included skin grafts, dermal substitutes, locoregional flaps, and free tissue transfer. Successful prosthetic salvage was associated with shorter time intervals between wound diagnosis and index reconstructive surgical intervention (median: 20 days for salvage vs 804 days for failure; P = .014). Additionally, salvage was associated with reduced time from the index orthopaedic/podiatric surgical intervention to the index reconstructive surgery procedure (12 vs 727 days; P = .027).

CONCLUSION

The prognosis of complicated TAA requiring soft-tissue reconstruction remains poor, especially in patients who present with infected joints. Several reconstructive techniques, ranging from simple skin grafts to complex free tissue transfers, can be used successfully. Early intervention to achieve soft-tissue coverage is crucial in maximizing salvage rates in the setting of complicated and infected TAA.

LEVEL OF EVIDENCE

Level IV.

Short-Term Outcomes of Primary Total Ankle Arthroplasty in Octogenarians: A National Database Analysis

BACKGROUND

Total ankle arthroplasty (TAA) is an increasingly popular option for end-stage ankle arthritis. Americans over the age of 80 years grew to 16.7 million in 2010, but there are scarce data assessing the outcomes of octogenarians undergoing TAA. This study evaluated (1) perioperative factors, (2) 30-day postoperative complications compared to a nonoctogenarian cohort, and (3) independent risk factors for adverse outcomes.

METHODS

A national database registry was queried for patients who had undergone primary TAA. This yielded 1113 patients, under (n = 1059) and over (n = 54) age 80 years. Demographics and perioperative data were compared using Fisher's exact, χ², and independent-samples t tests. Logistic and Poisson regressions were used to calculate odds ratio (OR) of complications and independent risk factors.

RESULTS

The octogenarian cohort had longer in-hospital length of stay (1.9 vs 2.5 days, P < .0001). Octogenarians were not significantly more likely to develop any complication (OR = 1.32; 95% confidence interval = 0.29-6.04; P = .722), or increased number of complications (OR = 1.18; 95% CI = 0.27-5.18; P = .820). Octogenarians had significantly increased risk of being discharged to rehab/skilled nursing (OR = 6.60; 95% CI = 2.16-20.15; P < .001) instead of home.

CONCLUSION

Although the elderly population may carry inherent risk factors, octogenarians do not present an increased risk of short-term complications following TAA.

LEVELS OF EVIDENCE

Therapeutic, Level III: Retrospective cohort study.

Total ankle replacement with INBONE-II prosthesis: A short-to-medium-term follow-up study in China

BACKGROUND

Total ankle replacement (TAR) is a viable option for the treatment of end-stage ankle arthritis. In China, the INBONE-II implant is the only total ankle prosthesis approved since 2016. The purpose of this study is to report a large sample of findings for the TAR with INBONE-II prosthesis.

METHODS

A total of 65 patients with end-stage ankle arthritis, who underwent primary TAR using INBONE-II by the same surgeon from 2016 to 2019, at a single institution were included in this retrospective, single-center study. Clinical data, radiographic findings, survival rate, and complications were recorded and assessed pre-operatively and at the most recent follow-up.

RESULTS

A total of 64 patients were available for follow-up at least 2 years after surgery; the mean follow-up duration for clinical outcomes was 37.9 months (24-59 months), and for radiographic findings was 22.8 months (12-59 months). There were significant improvements (P < 0.01) in the American Orthopedic Foot and Ankle Society hindfoot scale, the visual analog scale for pain, and the Short Form-36. There were statistically significant differences between pre-operative and post-operative comparisons of the talar tilt angle (TT) and the tibial lateral surface angle (TLS) in the radiographic findings (TT from 4.7 ± 4.3° to 1.3 ± 1.3°, TLS from 80.4 ± 7.7° to 87.4 ± 2.3°, P < 0.01). There was no statistically significant difference in improvement of the tibial anterior surface angle (P = 0.14). Ten complications (all low grade) were recorded according to the Glazebrook classification system. The survivorship of the prosthesis was 100% (64/64).

CONCLUSION

Patients who underwent TAR with INBONE-II prosthesis demonstrated significant improvements in all measures of pain and function as well as in radiographic findings. High survival and a low incidence of complications were observed in this study.

Utilization Trends of Total Ankle Arthroplasty and Ankle Fusion for Tibiotalar Osteoarthritis: A Nationwide Analysis of the United States Population

Introduction: Studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) are sparse. The purpose of this study was to use a nationwide administrative claims database to compare baseline demographics between TAA and ankle arthrodesis and to determine whether patients who had a TAA have increased rates of: (1) utilization, (2) in-hospital length of stay (LOS), and (3) costs of care. Methods: PearlDiver, a nationwide claims database was queried from 2005 to December 2013 for all patients who underwent primary TAA or AF for the treatment of osteoarthritis of the ankle and foot. Baseline demographics of age, sex, geographic distribution, and the prevalence of comorbidities comprising the Elixhauser comorbidity index (ECI) were compared between patients who had TAA and AF. Linear regression was used to compare differences in utilization and in-hospital LOS between the 2 cohorts during the study interval. Annual charges and reimbursement rates for TAA were assessed during the study period. A P value less than .05 was considered to be statistically significant. Results: A total of 21 433 patients undergoing primary TAA (n = 7126) and AF (n = 14 307) were included. Patients undergoing TAA had significantly greater ECI driven by arrythmias, congestive heart failure, diabetes mellitus, electrolyte/fluid disorders, iron deficiency anemia than patients undergoing AF (P < .001). From 2005 to 2013, TAA utilization increased from 21.5% to 49.4% of procedures (P < .0001). There was reduced in-hospital LOS over the time interval for patients with TAA compared with AF (2.15 days vs. 3.11 days, P < .0001). Total ankle arthroplasty reimbursements remained stable while charges per patient increased significantly from $40 203.48 in 2005 to doubling by the end of 2013 to $86 208.59 (P < .0001). Conclusion: This study demonstrated increased use of TAA compared to AF showing decreased in-hospital LOS and increased cost of care with stagnant reimbursement rates.Level of Evidence: Level III.

YouTube as a Source of Patient Information for Ankle Arthroplasty: Quantitative Analysis of Video Reliability, Quality, and Content

Background. There are limited data on the quality and content of videos discussing total ankle arthroplasty (TAA) on the YouTube video platform. Methods. The first 60 unique YouTube videos resulting from the keyword query "ankle arthroplasty" and "ankle replacement" were analyzed for comprehensiveness and quality. Content was assessed using the Journal of American Medical Association (JAMA) benchmark criteria, DISCERN, Global Quality Scale (GQS), and an arthroplasty-specific score. Results. Videos demonstrated low mean DISCERN (49.2/80), GQS (3.2/5), and arthroplasty-specific scores (4.3/12) with substantial variability between videos. Most of the content was produced by nonacademic physicians (46.7%) and academic sources (21.7%). Academic videos saw significantly higher mean JAMA scores (P = .013) but were otherwise comparable to non-academic physicians. Commercial content demonstrated significantly low-quality scores compared to academic (P = .012) and physician (P = .008) sources despite the highest mean viewership. Conclusions. Information on TAA on the YouTube platform is highly variable based on video source, with generally poor quality and content.Level of Evidence: Level V, systemic review of non-peer reviewed resources.

Factors Predictive of Early Complications Following Total Ankle Arthroplasty

Background:

The safety of outpatient total ankle arthroplasty (TAA), and factors predictive of early complications are poorly understood. The objective of this study was to determine the frequency of early complications in patients undergoing outpatient TAA compared to a matched inpatient TAA cohort. Factors predictive of early complications following TAA are elucidated.

Methods:

A retrospective review of prospectively collected data from the 2011-2018 American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database was performed. An unadjusted analysis comparing complication rates in outpatient, and inpatient TAA was performed followed by a propensity score–matched cohort analysis. A multivariate logistic regression model was then used to identify significant independent predictors for complications, reoperation, and readmission following TAA.

Results:

A total of 1487 patients (198 outpatient, 1289 inpatient) undergoing TAA were included in the study. Inpatient TAA was associated with increased 30-day readmission compared with outpatient TAA (3.54% vs 0.51%, P = .032) in a matched cohort analysis. Thirty-eight (2.6%) patients had a minor complication, with 16 (1.1%) patients having a major complication after TAR. Nineteen (1.3%) patients underwent reoperation, and 42 (2.8%) patients were readmitted within 30 days of the index TAR. Multivariate analysis identified factors predictive of early complications to include length of stay (LOS) >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus.

Conclusion:

From this relatively limited data set, outpatient TAA appears to be safe for management of end-stage ankle arthritis in select patients. Inpatient status was associated with an increased rate of 30-day readmission following TAA. Postoperative length of stay >2 days, smoking, hypertension, bleeding disorders, and diabetes mellitus were identified to be associated with early postoperative complications following TAA in this cohort.

Level of Evidence

Level III, retrospective cohort study.

Risk Factors for Complications, Longer Hospital Stay, and Readmission After Total Ankle Arthroplasty

BACKGROUND

Studies have shown conflicting results regarding associations of preoperative comorbidities with outcomes after total ankle arthroplasty (TAA). Our aim was to analyze preoperative risk factors for complications, longer hospital stay, and readmission within 30 days after TAA.

METHODS

We conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database. We included 294 patients who underwent TAA from 2009 through 2012. We used multivariate logistic regression to identify risk factors for complications, longer hospital stay, and hospital readmission.

RESULTS

Surgical site infection was the most common complication. Diabetes was associated with greater odds of complications as was current smoker status. Notably, obesity was not associated with greater odds of complications. Age, chronic obstructive pulmonary disease, and diabetes mellitus were associated with longer hospital stays. Surgical site infection was the most common reason for hospital readmission.

CONCLUSIONS

TAA has a low complication rate, with surgical site infection being the most common complication and the most common reason for hospital readmission. Patients with diabetes have greater odds of poor outcomes and prolonged hospital stays after TAA than patients without diabetes. Obesity was not associated with poor outcomes after TAA.

LEVELS OF EVIDENCE

Level III.

Distribution of High-Volume Ankle Replacement Surgeons in United States Metropolitan Areas

BACKGROUND

Ankle osteoarthritis is increasing, thus creating greater demand for high-volume total ankle arthroplasty (TAA) surgeons. The Medicare Provider Utilization and Payment Data Public Use File (MPUPD-PUF) provides volume and reimbursement data for procedures performed by physicians participating in Medicare. This study analyzes surgeon prevalence, surgeon distribution, and factors affecting surgeon prevalence in metropolitan areas.

METHODS

The MPUPD-PUF was reviewed from 2012 to 2015, and data were extracted for physicians performing ≥11 TAA procedures. Physicians in metropolitan areas (population >1 million) were grouped together, and reimbursement, number of high-volume surgeons, and procedures were calculated. Presence of an American Orthopaedic Foot and Ankle Society (AOFAS) fellowship program was analyzed for associations with high-volume TAA surgeons.

RESULTS

Fifty-three surgeons performed ≥11 TAA procedures (1,960 total) covered by Medicare. Of these surgeons, 66% practice in metropolitan areas with a population >1 million. Fifty-one percent of US major metropolitan areas contained no surgeon who submitted >10 traditional Medicare claims for TAA. Areas with an AOFAS fellowship had nominally more TAA claims submitted.

CONCLUSIONS

The distribution of high-volume TAA surgeons among major metropolitan areas in the United States is highly unequal. Analyzing the data with this method aids in targeting TAA surgeons to currently underserved areas.

LEVELS OF EVIDENCE

Level IV: Retrospective-comparative study.

Short-Term Complications and Outcomes of the Cadence Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) is an increasingly popular option for the operative treatment of ankle arthritis. The Cadence TAA entered clinical use in 2016 and was designed to address common failure modes of prior systems. We report early complications and radiographic and clinical outcomes of this total ankle system at a minimum of 2 years of follow-up.

METHODS

We performed a retrospective review of a consecutive cohort of patients undergoing primary Cadence TAA by a single surgeon from 2016 to 2017. Complications and reoperations were documented using the American Orthopaedic Foot & Ankle Society (AOFAS) TAA reoperation coding system. Patients completed the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and Sport subscales, SF-12 Mental (MCS) and Physical (PCS) Component Summaries, and visual analog scale (VAS) pain rating (0-100). Radiographic evaluation was performed to assess postoperative range of motion (ROM) of the sole of the foot relative to the long axis of the tibia, alignment, and implant complications.

RESULTS

Fifty-eight patients with a mean age of 63.3 years and mean body mass index of 31.9 kg/m² were included. Twelve of 58 patients (20.7%) underwent an additional procedure(s) within 2 years, including 3 (5.2%) who required removal of one or both components, 2 for infection and 1 for osteolysis. Forty-three patients were followed for a minimum of 2 years with radiographic imaging; 1 patient's (2.3%) radiographs had signs of peri-implant osteolysis, with no cases demonstrating loosening or subsidence. FAAM-ADL, FAAM-Sport, SF-12 PCS, and VAS pain scores all improved at a mean of 27.4 months postoperatively, with mean score changes (± SD) of 16.3 (± 22.0), 25.3 (± 24.5), 6.0 (± 11.1), and -32.3 (± 39.8), respectively. Radiographic analysis revealed that average coronal alignment improved from 6.9 degrees from neutral preoperatively to 2.3 degrees postoperatively. The average ROM of the foot relative to the tibia was 36.5 degrees total arc of motion based on lateral radiographs.

CONCLUSION

Early experience with this 2-component total ankle replacement was associated with a high component retention rate, improved coronal plane alignment, good postoperative ROM, radiographically stable implants, and improved patient function.

LEVEL OF EVIDENCE

Level IV, case series.

Short-Term Complications Following Total Ankle Arthroplasty and Associated Risk Factors: A NSQIP Database Analysis

INTRODUCTION

Total ankle arthroplasty (TAA) has become increasingly utilized over the past 20 years to treat osteoarthritis of the ankle. The efficacy and safety of this procedure has been previously reported, but relatively few studies have documented the risk of postoperative complications associated with TAA over the past 10 years. Thus, the aim of this study is to provide a current report on the safety of TAA, particularly in association with a number of preoperative risk factors.

METHODS

A retrospective review of all patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent TAA between 2012 and 2018 was performed. A total of 1333 patients were included in this analysis. Penalized logistic regression to consider small numbers of the postoperative complications was used to identify factors associated with incidence of the complications.

RESULTS

The rate of readmission and superficial wound infection were found to be 1.4% and 0.6%, respectively. Risk factors associated with a prolonged hospital stay were black race, Hispanic race, and smoking. Diabetes was associated with a significantly increased risk of readmission. Age, sex, body mass index, and steroid use were not associated with increased risk of postoperative complications.

CONCLUSION

In this study, the rate of surgical site infection and readmission in TAA was found to be relatively low, compared to published data on total knee arthroplasty and total hip arthroplasty. Both race and smoking increase the risk of prolonged hospital stay, while diabetes increases the risk of readmission.

LEVELS OF EVIDENCE

Level III, retrospective comparative trial.

Does the Canadian Orthopaedic Foot and Ankle Society Postoperative COFAS End-Stage Ankle Arthritis Classification System Correlate With Pre- and Postoperative PROMIS Scores for Total Ankle Arthroplasty?

Background:

Recently, the Canadian Orthopaedic Foot and Ankle Society (COFAS) proposed a classification system addressing adjunct procedures in the treatment for end-stage ankle arthritis. We reviewed Patient-Reported Outcome Measures Information System (PROMIS) data to determine if outcomes of total ankle arthroplasty (TAA) correlated with postoperative COFAS classification. We hypothesize that as COFAS classification increases, patients will demonstrate greater improvement in the change between pre- and postoperative PROMIS scores.

Methods:

From June 2015 to December 2018, a total of 127 patients underwent 132 TAA. Demographic factors and preoperative and most recent postoperative PROMIS scores were collected. Univariate, multivariate and post hoc analyses with a significance threshold of P <.05 were performed.

Results:

Eighty-seven patients with a mean follow-up of 13.6±7.3 months and complete PROMIS scores were classified into COFAS types 1-4. Significant differences were identified in the PROMIS Pain Interference domain comparing COFAS types 2 and 4 and COFAS types 3 and 4. These results demonstrate that more complex ankles with a higher COFAS score had worse interval improvement in PROMIS scores. Additionally, multivariate linear regression showed that age and BMI were associated with worse physical function and depression, whereas diabetes and a history of prior surgeries were associated with improved postoperative function.

Conclusion:

The COFAS postoperative classification system is useful for categorizing end-stage ankle arthritis. Further research into the ideal timing of surgery and higher-level studies to better determine TAA efficacy with different classification systems is warranted. This information can be helpful with preoperative counseling about treatment outcomes. Level of Evidence: Level IV, retrospective analysis of prospectively collected data.

Two-Year Revision Rates in Total Ankle Replacement Versus Ankle Arthrodesis

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.

30-Day Outcomes for Total Ankle Arthroplasty in Patients With Anemia

BACKGROUND

While anemia has been associated with poor surgical outcomes in total knee arthroplasty and total hip arthroplasty, the effects of anemia on total ankle arthroplasty remain unknown. This study examines how preoperative anemia affects postoperative outcomes in total ankle arthroplasty.

METHODS

A retrospective analysis was performed using the American College of Surgeons National Surgery Quality Improvement Project database from 2011 to 2018 for total ankle arthroplasty procedures. Hematocrit (HCT) levels were used to determine preoperative anemia.

RESULTS

Of the 1028 patients included in this study, 114 patients were found to be anemic. Univariate analysis demonstrated anemia was significantly associated with an increased average hospital length of stay (2.2 vs 1.8 days, P < .008), increased rate of 30-day readmission (3.5% vs 1.1%, P = .036), increased 30-day reoperation (2.6% vs 0.4%, P = .007), extended length of stay (64% vs 49.9%, P = .004), wound complication (1.75% vs 0.11%, P = .002), and surgical site infection (2.6% vs 0.6%, P = .017). Multivariate logistic regression analysis found anemia to be significantly associated with extended hospital length of stay (odds ratio [OR], 1.62; 95% CI, 1.07-2.45; P = .023) and increased reoperation rates (OR, 5.47; 95% CI, 1.15-26.00; P = .033). Anemia was not found to be a predictor of increased readmission rates (OR, 3.13; 95% CI, 0.93-10.56; P = .066) or postoperative complications (OR, 1.27; 95% CI, 0.35-4.56; P = .71).

CONCLUSION

This study found increasing severity of anemia to be associated with extended hospital length of stay and increased reoperation rates. Providers and patients should be aware of the increased risks of total ankle arthroplasty with preoperative anemia.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Early Failure of Total Ankle Arthroplasty in a Patient with Ipsilateral Varus Knee Deformity

Multiple risk factors such as age, body mass index (BMI), preoperative diagnosis, smoking, diabetes mellitus, malalignment of an implant, and presence of ipsilateral hindfoot fusion have been shown to contribute to failure of total ankle arthroplasty (TAA). However, the exact causes of TAA failure remain uncertain, and various causes can lead to a need for revision surgery. We report a case of early aseptic loosening of the implant following TAA in a patient with severe varus deformity of the ipsilateral knee.

The Agility Total Ankle Arthroplasty: A Concise Follow-up at a Minimum of 20 Years

BACKGROUND

Between 1984 and 1994, a single surgeon performed 132 primary cementless total ankle replacements using the Agility total arthroplasty system. The purpose of this study was to report on the 20-year follow-up, which we believe is the first study with this length of follow-up.

METHODS

Living patients were contacted and interviewed to determine the status of their implant (revised or unrevised) and to answer a simple questionnaire concerning overall satisfaction, pain, and functional improvement, as in a previous study. Thirty-three (26.2%) patients with 33 (25%) ankles of the original series were alive at a minimum of 20 years postoperatively, with a median follow-up of 22 years. They were asked to return to the office for standing anteroposterior and lateral ankle and foot radiographs or to send these radiographs if performed elsewhere. Radiographs were evaluated for radiolucencies around the components and subsidence (talar component) or migration (tibial component) of components.

RESULTS

Seventeen (13.5%) ankles of the 126 available for follow-up, including 5 (15.2%) ankles in living patients, had undergone revision (n = 10) or arthrodesis (n = 7) for loosening. One additional ankle was revised for infection and 1 for talar component malposition; thus, 19 (15.1%) ankles were revised.

CONCLUSION

These results should provide a 20-year benchmark for newer total ankle arthroplasty designs when a similar length of follow-up becomes available.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Outpatient total ankle replacement

INTRODUCTION

Since the development of the last generation of implants total ankle replacements (TAR) is becoming more and more popular in patients and in specialized surgeon teams, the trend for outpatient surgery is growing, and protocols now are well established for hip or knee replacement. We adapted a protocol for outpatient TAR and hypothesized that it could be performed safely as standard procedure.

PATIENTS AND METHODS

Twenty-five consecutive patients among 141 TAR were treated with our outpatient protocol relying on three fundamentals: bleed control, pain control, and autonomy. They received 1 g of tranexamic acid before surgery, and after discard from post-operative care unit, they were operated under long-lasting nerve block precociously relayed by oral NSAIDs and had an immediate full weight-bearing authorization at discharge.

RESULTS

No patients we readmitted for an acute care following TAR, especially for haematoma or uncontrolled pain. Mean VAS was < 1 before discharge from post-operative care unit and < 2 until day 90. One patient had a delayed wound healing treated surgically at day 30 without implant revision.

CONCLUSION

Outpatient TAR is possible and safe if a risk management process is used, and the three basic principles for outpatient procedures are respected: bleed control, pain control, and patient autonomy. We consider now this modality as a routine.