Clinical Outcomes and Complications of Simultaneous or Sequential Bilateral Total Ankle Arthroplasty: A Single-Center Comparative Cohort Study

Outcomes of Bilateral Scandinavian Total Ankle Replacement: A Detailed Analysis of Implant Survivability and Patient-Reported Outcomes

Background

Total ankle replacement (TAR) is an established treatment for end-stage ankle arthritis, offering pain relief and improved functionality. The Scandinavian Total Ankle Replacement (STAR) was first used in the United States in 1998 and although unilateral STAR has been extensively studied, there is limited documentation on the outcomes of simultaneous bilateral STAR procedures. This study aimed to evaluate the survivability and patient-reported outcomes of simultaneous bilateral STAR, focusing on implant survival rates and improvements in quality of life, function, and pain relief.

Methods

A retrospective cohort study was conducted on all patients managed with primary TAR performed simultaneously with bilateral STAR prostheses at our institution from July 1998 to February 2008. Demographics and perioperative characteristics were collected. Poisson regression was used for analyzing implant survivability, and generalized linear mixed models were applied to assess patient-reported outcomes, including the visual analog scale (VAS), Short Musculoskeletal Function Assessment (SMFA), 36-Item Short Form Health Survey (SF-36), and American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, at multiple follow-up time points.

Results

Twenty-one patients were included for a total of 42 implants. The average length of follow up was 4.9 ± 2.7 years. The implant failure rate at 5 years was 12.0% (95% CI 4.5%-32.0%). The last recorded failure occurred at 8 years postimplant, with an implant failure rate of 19.2% (95% CI 17.2%-51.1%). Statistically significant improvements were observed in all patient-reported outcome measures from baseline to the 5-year follow-up (P < .05) except SMFA bother because of high variability and small sample size.

Conclusion

At midterm follow-up, patients who underwent bilateral simultaneous TAR with the STAR prosthesis experienced a significant and durable improvement in patient-reported outcome scores across multiple functional indices. Failure rates were within range to those reported in previous studies evaluating unilateral STAR, with an estimated average survivorship of 80.8% at 8 years.

Level of Evidence

Level IV, case series.

Gait asymmetry persists following unilateral and bilateral total ankle arthroplasty

Total ankle arthroplasty (TAA) improves gait symmetry in patients with unilateral end-stage ankle arthritis but has not been studied in patients undergoing bilateral TAA (B-TAA), and few studies compare TAA patients to control subjects. The purpose of this study was to compare gait symmetry in U-TAA and B-TAA patients and healthy controls. Using prospective databases, 19 unilateral and 19 bilateral ankle arthritis patients undergoing TAA were matched to 19 control subjects by age, sex, and BMI. The Normalized Symmetry Index (NSI) was determined for joint mechanics and ground reaction forces (GRF) during walking trials at a single visit for controls and preoperatively and 1 to 2 years postoperatively for TAA patients. Data was analyzed using linear mixed-effects models to determine differences among time points and cohorts at a significance of α = 0.05. Following surgery, B-TAA and U-TAA experienced improved peak plantarflexion moment symmetry (p = 0.017) but remained less symmetric than controls. B-TAA patients had more symmetry than U-TAA patients during peak weight acceptance GRF (p = 0.002), while U-TAA patients had greater peak dorsiflexion symmetry than B-TAA patients. TAA patients demonstrated more asymmetry compared to control subjects for all outcome measures. There was no significant impact of TAA on gait symmetry for GRF or peak ankle angles, and neither U-TAA nor B-TAA was consistently associated with higher gait symmetry. These results indicate that TAA improves symmetry during peak plantarflexion moment, and that significant gait asymmetry persists for B-TAA and U-TAA patients compared to healthy participants.

Sequential bilateral total ankle replacements: No difference in patient-reported outcomes between the first and second ankle

BACKGROUND

Total ankle replacement is an established treatment for end-stage arthritis. However, there is little data examining outcomes in sequential bilateral replacements. This study aimed to compare outcomes between first and second ankles in sequential replacement.

METHODS

Patients were retrospectively contacted to complete a follow-up questionnaire including the Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D-3 L, and a question assessing satisfaction. Electronic records identified demographics, procedural details, and complications.

RESULTS

Twenty patients underwent sequential bilateral ankle replacement over the study period. At a mean follow-up of four years, 18 patients completed the follow-up questionnaire. There was no statistically significant difference between first and second ankles in terms of MOXFQ score, EQ-5D-3 L or satisfaction. Eleven complications were noted.

CONCLUSIONS

We report excellent outcomes after sequential bilateral ankle replacement with no difference in outcomes between first and second ankles. These results can be used to counsel patients in the future and manage expectations.

LEVEL OF EVIDENCE

IV.

Clinical Outcomes and Registry Data in Total Ankle Arthroplasty

Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis consistently demonstrating good to excellent outcomes, even when considering factors such as deformity, patient age, bilaterality, and arthritis etiology. There is little consensus in the literature with regard to preferred patient-reported outcome metrics (PROMs) for assessing outcomes, although all metrics generally improve following TAA. Several countries have successful registries to track longevity of TAA in populations; however, PROMs are generally not successfully tracked in registries. A trend toward consensus on outcome metrics and collaborative registries is warranted to optimize patient selection and outcomes in TAA.

Bilateral Total Ankle Arthroplasty

Patients with bilateral ankle arthritis have higher rates of primary and secondary/inflammatory arthritis and a more debilitating condition than those with unilateral pathology. The limited bilateral total ankle arthroplasty (TAA) literature supports both 1-surgeon and 2-surgeon team bilateral TAAs as safe and effective with comparable improvements in patient-reported outcome measures (PROMs), complications, reoperations, and prosthesis survival as unilateral TAA and staged bilateral TAA. Additional benefits of bilateral arthroplasty supported in the hip and knee literature include cost reduction, noninferior and even superior perioperative complication profiles, improved PROM and satisfaction, shorter recovery time, early rehabilitation, and less time away from employment.