Total ankle arthroplasty in the rheumatoid patient

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.

Trends in treatment of advanced ankle arthropathy by total ankle replacement or ankle fusion

BACKGROUND

Total ankle replacement (TAR) and ankle fusion (AF) are the 2 major operative options for treatment of advanced ankle arthropathy; there is, however, no large epidemiologic study comparing nationwide trends of these 2 procedures. The current study used a nationwide database to compare epidemiologic profiles of TAR and AF.

METHODS

Data collected for the Nationwide Inpatient Sample (NIS) from 2000 to 2010 were reviewed. Procedures were identified by searching for ICD-9-CM codes 81.11 (AF) and 81.56 (TAR). Patients' demographics and comorbidities, geographic distribution, and cost of procedures were compared.

RESULTS

The NIS analysis identified 2666 TAR and 16 419 AF cases which was extrapolated to 13 145 TAR and 80 426 AF nationwide. Spearman's ρ showed an increase in the number of AF per year while the number of TAR cases remained relatively flat per year until 2006, after which there was a steady increase in the number of TAR performed. Patients receiving a TAR tended to be older, female, and white. Patients who underwent AF were more likely to be obese or diabetic than TAR patients. Both TAR and AF were performed more frequently in private urban hospitals through 2007. However, in 2010, the number of TAR procedures was greater in academic centers compared to private urban hospitals.

CONCLUSIONS

Despite recent increases in the number of TAR implanted, AF was still performed more than 6 times more frequently for advanced ankle arthropathy. A trend was demonstrated toward an increasing number of TAR being implanted in academic centers, and in patients with more underlying comorbidities than was previously seen.

LEVEL OF EVIDENCE

Level II, prognostic study.

Long-term follow-up of mobile-bearing total ankle replacement in patients with inflammatory joint disease

Little is known about the long-term outcome of mobile-bearing total ankle replacement (TAR) in the treatment of end-stage arthritis of the ankle, and in particular for patients with inflammatory joint disease. The aim of this study was to assess the minimum ten-year outcome of TAR in this group of patients. We prospectively followed 76 patients (93 TARs) who underwent surgery between 1988 and 1999. No patients were lost to follow-up. At latest follow-up at a mean of 14.8 years (10.7 to 22.8), 30 patients (39 TARs) had died and the original TAR remained in situ in 28 patients (31 TARs). The cumulative incidence of failure at 15 years was 20% (95% confidence interval (CI) 11 to 28). The mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score of the surviving patients at latest follow-up was 80.4 (95% CI 72 to 88). In total, 21 patients (23 TARs) underwent subsequent surgery: three implant exchanges, three bearing exchanges and 17 arthrodeses. Neither design of TAR described in this study, the LCS and the Buechel-Pappas, remains currently available. However, based both on this study and on other reports, we believe that TAR using current mobile-bearing designs for patients with end-stage arthritis of the ankle due to inflammatory joint disease remains justified.

Thrombembolic complications after total ankle replacement

The literature addressing functional outcome and survivorship of prosthesis components is constantly growing. However, the data on thromboprophylaxis and thrombembolic complications in patients who underwent TAR are scarce. A total of 31 studies were included in the systemic literature review. The incidence of thrombembolic complications varied between 0.0 % and 9.8 %. Most commonly, low molecular weight heparin was used as thromboprophylaxis for 6 weeks postoperatively. The incidence of thrombembolic complications was comparable with that of symptomatic deep vein thrombosis in patients with total knee or hip replacement.

Total ankle replacement: a historical perspective

In the early 1970s, total ankle replacement was criticized because of poor outcomes with initial implant designs. Modifications were made that lead to the development of several generations of implants. The early shortcomings gave researchers and surgeons the impetus to improve implant designs and surgical technique. Total ankle replacement has become more widely accepted in recent years because of improved design and survivorship rates for the implants, as well as improved patient satisfaction scores. Indications for total ankle replacement have broadened. To continue these successes, it is important for surgeons to select appropriate patients for this procedure.

End-stage ankle arthritis: arthrodiastasis, supramalleolar osteotomy, or arthrodesis?

End-stage ankle arthritis is a debilitating condition that leads to pain and swelling in the ankle joint, with symptoms aggravated by standing and ambulation. Ankle arthritis commonly results from a history of trauma, or a series of recurrent injuries to the ankle. However, it may develop from other causes such as uneven loading of the ankle joint caused by an alignment deformity or from inflammatory arthritis such as rheumatoid arthritis, gout, or secondary to a serious joint infection. Patients with severe ankle arthritis often have limited ankle motion with an antalgic gait.

Total ankle replacement for treatment of end-stage osteoarthritis in elderly patients

End-stage osteoarthritis of the ankle is a disabling problem, particularly in elderly patients who experience an overall loss of mobility and functional impairment and who then need compensatory adaption. Ankle arthrodesis, which has been demonstrated to provide postoperative pain relief and hindfoot stability, leaves the patient with a stiff foot and gait changes. For elderly patient, these changes may be more critical than generally believed. Additionally, the long duration of healing and rehabilitation process needed for ankle arthrodesis may be problematic in the elderly. In contrast to ankle arthrodesis, total ankle replacement has significant advantages including a less strenuous postoperative rehabilitation and preservation of ankle motion which supports physiological gait. Recently, total ankle replacement has evolved as a safe surgical treatment in patients with end-stage ankle osteoarthritis with reliable mid- to long-term results. Total ankle replacement needs less immobilization than arthrodesis and does allow for early weight-bearing and should be considered as a treatment option of first choice in many elderly patients with end-stage osteoarthritis of the ankle, especially in elderly patients with lower expectations and physical demands.

Total ankle replacements: an overview

One of the most widely debated topics amongst foot and ankle surgeons is the treatment of end stage arthritis. With the advent of the newer generation of total ankle replacement (TAR), a viable option over an arthrodesis is now available for patients with end-stage ankle arthritis. When compared with an ankle arthroplasty, recent reports suggest the ankle arthrodesis has poor long-term outcomes (20 years+) and can experience short- and long-term complications. Proper training, strict patient selection, and proper implant contribute to a successful outcome. As advances continue to be made in both implant design and surgical technique, the benefits of a TAR appears to provide the foot and ankle surgeon a good alternative for the appropriate patient.