Total Ankle Arthroplasty: Does Obesity Matter?

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.

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.

Five-Year Revision Surgery Rates After Total Ankle Arthroplasty and Ankle Arthrodesis in Patients With Prior Bariatric Surgery: A Retrospective Cohort Study

INTRODUCTION

It is unclear how bariatric surgery for the treatment of obesity may affect outcomes of surgical treatment for ankle conditions. The purpose of this study was to compare rates of revision surgery after primary ankle arthrodesis ("arthrodesis") and total ankle arthroplasty ("arthroplasty") for patients who had undergone bariatric surgery and those who had not ("control group").

METHODS

In this retrospective study, we used data from the PearlDiver database to compare 5-year revision surgery rates after arthroplasty and arthrodesis in patients with and without a history of bariatric surgery. Cohorts were propensity-matched by age, sex, and Charlson Comorbidity Index value in a 1:4 ratio. We explored the following surgical outcomes: arthroplasty revision, joint infection, instrumentation removal, open reduction and internal fixation (ORIF), and adjacent joint fusion. Cumulative incidence was calculated through Kaplan-Meier survival analysis and compared using Cox proportional hazard ratios.

RESULTS

At 5 years after arthrodesis, the likelihood of adjacent joint fusion was higher among patients with a history of bariatric surgery than among control patients (hazard ratio: 1.8, 95% confidence interval, 1.2 to 2.6); however, we found no differences in surgical outcomes for joint infection, instrumentation removal, or ORIF. At 5 years after arthroplasty, surgical outcomes did not differ between those with a history of bariatric surgery versus control patients.

DISCUSSION

These findings suggest that a history of bariatric surgery is not an important predictor of joint infection, instrumentation removal, or ORIF within 5 years after primary total ankle arthroplasty or arthrodesis. When choosing between arthroplasty or arthrodesis in patients who have undergone bariatric surgery, higher incidence of adjacent joint fusion should be a consideration.

LEVEL OF EVIDENCE

III, Retrospective cohort study.

Radiographic soft tissue thickness is not a risk factor for infection after primary total ankle arthroplasty

As the incidence of total ankle arthroplasty (TAA) for the management of end-stage arthritis is on the rise, identification of risk factors for periprosthetic joint infection (PJI) is essential. There has been limited research exploring the use of radiographic soft tissue thickness in TAA despite its predictive value in other forms of arthroplasty. This study evaluated the predictive capabilities of radiographic soft-tissue thickness for PJI following TAA. A retrospective analysis of 323 patients at a single institution who underwent primary TAA from 2003 to 2019 was conducted. Patient demographics, comorbidities, indication for surgery, prosthesis type and tourniquet time were recorded. Tibial-Tissue and Talus-Tissue distances were measured on preoperative lateral radiographic imaging. Logistic regression was utilized to determine the Odds Ratio (OR) of risk factors for the occurrence of PJI. Of the 323 patients, 6 patients (1.86 %) developed a PJI. Average duration of follow-up was 8.42 ± 2.52 years. Neither Tibial-Tissue (OR = 0.975; 95 % CI [0.947 - 1.004]; p = 0.09) nor Talus-Tissue thickness (OR = 0.976; 95 % CI [0.940 - 1.012]; p = 0.18) were significant predictors of PJI. Although not statistically significant, the infected cohort had smaller average Tibial-Tissue (2.20 vs. 2.53 cm; p = 0.05) and Talus-Tissue thickness (2.19 vs. 2.44 cm; p = 0.36) compared to the non-infected cohort. Measurements such as Tibial-Tissue length and Talus-Tissue length were not significant predictors of PJI following primary TAA. These findings underscore the necessity for additional research to identify modifiable risk factors aimed at reducing PJI rates and enhancing patient outcomes. LEVEL OF EVIDENCE: III, Retrospective Comparative Study.

Higher BMI Is Associated With Wound Breakdown Following Resection of Haglund Deformity

BACKGROUND

Haglund deformity is characterized by an enlarged posterosuperior calcaneus, often with inflammation of the retrocalcaneal bursa and Achilles tendon. This study aims to determine if obesity is associated with an increased rate of complications after Haglund resection.

METHODS

A retrospective review was conducted on patients who underwent surgical resection for Haglund deformity from January 2015 to December 2023 at a single academic center. The patient cohort was initially stratified by body mass index (BMI) into normal (BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30). For those classified as obese, further subclassification was performed using the standard system: obesity class I (mild obesity) = BMI 30.0-34.9; obesity class II (moderate obesity) = BMI 35.0-39.9; and obesity class III (severe obesity) = BMI ≥40.0. Data on demographics, surgical techniques, and weightbearing were collected and analyzed. Postoperative complications were compared between groups.

RESULTS

Of the 370 patients included in this study, 20 (5.4%) were classified as normal, 77 (20.8%) were overweight, and 273 (73.8%) were obese. Within the cohort of patients with obesity, 96 (35.2%) were classified as obesity class I, 96 (35.2%) as obesity class II, and 81 (29.7%) as obesity class III.The obese group had a higher proportion of females (70.0%) and Black/African American race (24.5%), and a higher prevalence of diabetes mellitus (22.0%) and American Society of Anesthesiologists scores compared with other groups. Additionally, analysis within the obesity subclassifications revealed significant differences in smoking status, with a higher proportion of nonsmokers as obesity class increased (58.3% in class I, 76.0% in class II, and 79.0% in class III; P = .01). Follow-up duration averaged 10.5 months, with wound breakdown rates significantly higher in the obese group vs the overweight or normal groups (11.0% vs 2.6% vs 0.0%, P = .02). No significant differences in wound complications or outcomes were observed between patients based on different obesity subclassifications.

CONCLUSION

Our findings demonstrate that after Haglund resection, obese patients have a higher risk of complications, particularly wound breakdown. This underscores the necessity of careful patient selection and perioperative optimization.

Association of Radiographic Soft Tissue Thickness With Revision Total Ankle Arthroplasty Following Primary Total Ankle Arthroplasty: A Minimum of 5-year Follow-up

Background

The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA.

Methods

A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative radiographs. Two novel radiographic measures of soft tissue thickness were developed and assessed (tibial tissue thickness and talus tissue thickness). Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA.

Results

The rate of revision surgery was 4.3% (14 of 323 patients). Patients requiring revision had significantly greater tibial tissue (3.54 vs 2.48 cm; P = .02) and talus tissue (2.79 vs 2.42 cm; P = .02) thickness compared with those not requiring revision. Both the tibial tissue thickness (odds ratio 1.16 [1.12-1.20]; P < .01) and the talus tissue thickness (odds ratio: 1.10 [1.05-1.15]; P < .01) measurements were significant predictors of revision TAA in multivariable logistic regression models. However, BMI was not a significant predictor of revision TAA. The two metrics demonstrated excellent interrater reliability.

Conclusion

Greater soft tissue thickness was a better predictor of revision TAA compared with BMI. These findings suggest that radiographic soft tissue thickness may be a valuable tool for assessing the risk of the need for revision TAA following primary TAA. Further research is needed to validate and explore the potential impact on clinical practice.

Level of Evidence

Level III, comparative study.

Obesity and Ankle Prosthesis Revision: A Systematic Review and Meta-analysis

BACKGROUND

The increasing number of total ankle arthroplasties (TAAs) has led to growing evidence on the risk factors for complications after surgery. However, the role of obesity in this patient group has been the subject of much debate. Therefore, this systematic review aimed to investigate the evidence for untoward effects of obesity following TAA.

METHODS

We conducted a comprehensive search on April 28, 2023, in MEDLINE (via PubMed), Embase, and CENTRAL. Eligible observational studies reported on the short- and long-term outcomes of primary TAA, comparing patients with and without obesity (defined as body mass index > 30). Using a random effects model, we calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) from 2 by 2 tables (event and nonevent in the obese and nonobese primary TAA groups).

RESULTS

Nine studies with 10 388 patients were eligible for inclusion in the meta-analysis. We found significantly higher odds of revision in the obese group compared to the nonobese group (OR = 1.68, CI: 1.44-1.95). However, the odds of overall perioperative complications (OR = 1.55, CI: 0.50-4.80) and wound complications (OR = 1.34, CI: 0.29-6.20) were nonsignificantly higher in the obese group.

CONCLUSION

Based on our results, obesity may have affected long-term outcomes following TAA and may have negatively affected the prosthesis's survival.