Do preoperative patient-reported outcomes predict hospital length of stay for surgically-treated end-stage ankle osteoarthritis patients?

Outcome Reporting in Total Ankle Arthroplasty: A Systematic Review

Total ankle arthroplasty is an increasingly utilized treatment for ankle arthritis due to decreasing failure rates and improved outcomes. However, the literature on this procedure remains heterogeneous with large variability in outcome reporting methods. PRISMA guidelines were used to systematically review outcome reporting measures used in prospective studies and randomized control trials on total ankle arthroplasty published in 15 high-impact journals between Jan 1, 2009-May 1, 2020. A total of 43 studies were included and outcome measures were grouped into seven categories: pain, subjective function, patient satisfaction, complications, objective function, implant survivorship, and imaging. The most common topic of study was implant design followed by differences in outcomes when comparing total ankle arthroplasty and arthrodesis. The most commonly reported outcome measure was post-surgical complications. No study reported on all seven categories, while 22 (51.2%) studies reported on four or more. Subjective measures had significant variability with fifteen different Patient Reported Outcome Measures used across the studies. While the included studies were quite comprehensive, there was little consistency in reporting outcomes after total ankle arthroplasty. With improving outcomes and techniques in total ankle arthroplasty, and thus an expected increase in utilization and number of published studies, efforts should be made to use commonly employed outcome reporting methods to facilitate comparison of results across studies.

Effect of Patient Demographics on Minimally Important Difference of Ankle Osteoarthritis Scale Among End-Stage Ankle Arthritis Patients

BACKGROUND

Ankle replacement and ankle arthrodesis are standard treatments for treating end-stage ankle arthritis when conservative treatment fails. Comparing patient-reported outcome scores to the instrument's minimal important difference (MID) helps physicians and researchers infer whether a meaningful change in health from the patient's perspective has occurred following treatment. The objective of this study was to estimate the MID of the Ankle Osteoarthritis Scale among a cohort of operatively treated end-stage ankle arthritis patients undergoing ankle replacement or arthrodesis.

METHODS

A survey package including the Ankle Osteoarthritis Scale was completed by participants preoperatively and 2 years postoperatively. Distribution and anchor-based approaches to calculating the MID were used to estimate the MID of the Ankle Osteoarthritis Scale and its 2 domains. The distribution-based approaches used were the small and medium effect size methods, while the mean absolute change method and linear regression method were the anchor-based approaches. Bootstrap sampling was used to obtain the variance of MID estimates. The MID was estimated for sex, age, operative, and baseline health subgroups. The cohort comprised 283 participants, totaling 298 ankles.

RESULTS

The MID did not vary with sex or operative procedure. Age-based differences in MID values may exist for the Ankle Osteoarthritis Scale total score, and MID values were generally smallest among the oldest patients. Patients with the best and worst ankle-related health preoperatively had higher MID values than patients reporting mid-range Ankle Osteoarthritis Scale values preoperatively.

CONCLUSION

The best estimate of the MID of the Ankle Osteoarthritis Scale total score is 5.81. Our findings indicate that the MID of the Ankle Osteoarthritis Scale may not vary by sex or operative subgroups but likely varies by age and preoperative Ankle Osteoarthritis Scale score.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Overall Health and the Influence of Physical Therapy on Physical Function Following Total Ankle Arthroplasty

BACKGROUND

The overall health and the importance of physical therapy for people following total ankle arthroplasty (TAA) have been understudied. Our purpose was to characterize the overall health of patients following TAA, and explore the frequency, influence, and patient-perceived value of physical therapy.

METHODS

People who received a TAA participated in this retrospective cohort online survey study. The survey included medical history questions and items from the Patient-Reported Outcomes Measurement Information System (PROMIS) Short Forms. Seven PROMIS domains, reflecting the biopsychosocial model of care (physical, mental, social), were included to examine participant overall health status in comparison to the general population. Items regarding physical therapy participation (yes/no), number of visits, and perceived value (scale 0-10; 10 = extremely helpful) were also included. Descriptive statistics were generated for participant characteristics, PROMIS domain T scores, and physical therapy questions. The influence of participant characteristics or physical therapy visits on PROMIS domain T scores that scored below the population mean were examined with multiple linear regression or ordinal regression.

RESULTS

The response rate was 61% (n=95). Average postoperative time was approximately 3 years (mean [SD]: 40.0 [35.3] months). Physical function and ability to participate in social roles and activities domain T scores were at least 1 SD below the population mean. Most patients received physical therapy (86%; 17.1 [11.0] visits) and found it helpful (7.2 [3.0]). Participant characteristics were minimally predictive of physical function and social participation T scores. Number of physical therapy visits predicted physical function T scores (P = .03).

CONCLUSIONS

Most health domain scores approached the population mean. Physical therapy was perceived to have a high value, and greater visits were related to greater physical function. However, lower physical function and social participation scores suggest that postoperative care directed toward these domains could improve the value of TAA and promote overall health.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Health and Quality of Life Outcomes Among Patients Undergoing Surgery for End-Stage Ankle Arthritis

BACKGROUND

There is little research investigating which aspects of health-related quality of life change following ankle arthrodesis and total ankle replacement surgery. The objective of this study was to report on statistically and clinically relevant changes in multiple dimensions of health-related quality of life among patients undergoing ankle replacement or fusion surgery.

METHODS

This study was based on a prospective sample of ankle arthrodesis and total ankle replacement patients. Participants complete the Ankle Osteoarthritis Scale, EuroQoL's EQ-5D-3L, the Patient Health Questionnaire-9, and the pain intensity, interference with enjoyment of life, and general activity pain instrument. Instruments were completed preoperatively and postoperatively. Multivariate regression models were used to measure the change in health-related quality of life outcomes, adjusting for demographic, clinical, and health service utilization.

RESULTS

Participants achieved statistically significant improvements in health-related quality of life in each domain of measurement. The majority of participants reported clinically significant improvement in pain. Mild depressive symptoms were common, and clinically significant improvement in depression symptoms occurred in 22% of patients. Gains in health were more pronounced among participants reporting the worst preoperative health in all domains quality of life measured.

CONCLUSIONS

Pain showed a clinically important improvement among 64% of participants whereas 22% reported a clinically meaningful improvement in their depression symptoms postoperatively. Clinically significant gains in health-related quality of life were not experienced by all participants in all dimensions. Further research is warranted to better understand the failure of some patients to improve in dimensions of health studied.

LEVEL OF EVIDENCE

Level III, comparative study.

Effect of Total Ankle Arthroplasty and Ankle Arthrodesis for Ankle Osteoarthritis: A Comparative Study

Background

Surgical methods in treatment of joint osteoarthritis (OA) aim at meeting the increasing expectations of people with active lifestyles. Ankle joint arthroplasty has been performed increasingly more often as an alternative to arthrodesis. The aim of this study was to compare arthrodesis and arthroplasty in the treatment of ankle osteoarthritis.

Material/Methods

The study involved 56 patients (45 males and 11 females) aged 21–72 years (mean 51) presenting with end-stage ankle OA: 29 patients (52%) underwent arthroplasty (Group A) and 27 patients (48%) underwent arthrodesis (Group B). Patients underwent surgery between 2004 and 2016 at a single clinical center. The observation period ranged from 6 to 150 months (mean 55 months). To assess the results of surgical treatment, quality of life (Health Assessment Questionnaire-HAQ, 12-Item Short-Form Survey-SF-12) and functional (American Orthopedic Foot & Ankle-AOFAS, Kofoed, Takakura) scores were used. For pain assessment, Visual Analog Scale was used (VAS).

Results

After the surgery, group A and B had a statistically significant improvement in the joint function and pain relief according to AOFAS (A: 32.6 to 68.2; B: 27.4 to 61.3), Kofoed (A: 31.8 to 68; B: 25.9 to 60.3), Takakura (A: 30.6 to 62.9; B: 25.4 to 49.3), and VAS scores (A: 7.28 to 4.14; B: 7.33 to 3.78) compared with preoperative scores. After the surgery, quality of life scores improved in both groups, for HAQ (A: 0.91 to 0.53; B: 1.34 to 0.56) and for SF-12 (A: 26.6 to 36.8; B: 25.6 to 38.0).

Conclusions

The comparison of total ankle arthroplasty and ankle arthrodesis in treatment of end-stage ankle osteoarthritis did not reveal any significant differences.