Total Ankle Arthroplasty and Ankle Arthrodesis Use: An American Board of Orthopaedic Surgery Part II Database Study

Trends and Reported Complications in Ankle Arthroplasty and Ankle Arthrodesis in the State of New York, 2009-2018

Background:

Ankle arthroplasty has emerged as a viable alternative to ankle arthrodesis due in large part to recent advancements in both surgical technique and implant design. This study seeks to document trends of arthroplasty and arthrodesis for ankle osteoarthritis in New York State from 2009-2018 in order to determine if patient demographics play a role in procedure selection and to ascertain the utilization of each procedure and rates of complications.

Methods:

Patients 40 years and older from 2009-2018 were identified using International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10), Clinical Modification (CM) diagnosis and procedure codes for ankle osteoarthritis, ankle arthrodesis, and ankle arthroplasty in the New York statewide planning and research cooperative system database. A trend analysis for both inpatient and outpatient procedures was performed to evaluate the changing trends in utilization of ankle arthrodesis and ankle arthroplasty over time. A multivariable logistic regression was used to assess the odds of receiving ankle arthrodesis relative to ankle arthroplasty. Complications were compared between inpatient ankle arthrodesis and arthroplasty using multivariable Cox proportional hazards regression.

Results:

A total of 3735 cases were included. Ankle arthrodesis increased by 25%, whereas arthroplasty increased by 757%. African American race, federal insurance, workers compensation, presence of comorbidities, and higher social deprivation were associated with increased odds of having an ankle arthrodesis vs an ankle arthroplasty. Compared with ankle arthroplasty, ankle arthrodesis was associated with increased rates of readmission, surgical site infection, acute renal failure, cellulitis, urinary tract infection, and deep vein thrombosis.

Conclusion:

Ankle arthroplasty volume has grown substantially without a decrease in ankle arthrodesis volume, suggesting that ankle arthroplasty may be selectively used for a different population of patients than ankle arthrodesis patients. Despite the increased growth of ankle arthroplasty, certain patient demographics including patients from minority populations, federal insurance, and from areas of high social deprivation have higher odds of receiving arthrodesis.

Level of Evidence:

Level III, retrospective cohort.

Volume and Variability of Foot and Ankle Case Exposure During Orthopaedic Residency: 2014-2019

BACKGROUND

Exposure to a comprehensive breadth and volume of surgical cases is a fundamental component of orthopaedic education, though standardization of case exposures across residency programs is limited to a small amount of required case minimums. Significant variability in exposure to subspecialty cases, such as foot and ankle surgeries, can create distinctly different residency experiences.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) surgical case logs from 2014 to 2019 for leg/ankle and foot/toes were examined following the 2013 implementation of case minimums. Average surgical case volume across subcategories and the average volume of different residency percentiles were analyzed to assess variability.

RESULTS

The mean total volume of case exposure for graduating orthopaedic residents has increased significantly since 2014 for both leg/ankle cases (28.6%) and foot/toes (27.8%), though totals were still down compared with when ACGME reporting began in 2007. Arthrodesis exposures have increased significantly for leg/ankle (69.2%) and foot/toes (93.8%) cases since 2014, and ankle arthroscopy has increased 20.7%. Disparities in total cases between 10th and 90th percentile programs have shown a nonsignificant decrease over time, with significant differences between leg/ankle arthrodesis (8-fold), leg/ankle arthroscopy (13-fold), and foot/toe arthrodesis (3.5-fold) in 2019.

CONCLUSION

The mean volume of foot and ankle case exposures among graduating residents has continued to rise since the implementation of case minimums in 2013 but disparities in volume are present, most notably concerning arthrodesis and arthroscopy. Recognition and future attention toward addressing this variability can be meaningful in promoting a more comprehensive, standardized orthopaedics education.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.

Unicompartmental Knee Arthroplasty Utilization among Early Career Surgeons: An Evaluation of the American Board of Orthopaedic Surgery Part-II Database

An updated understanding of unicompartmental knee arthroplasty (UKA) utilization is needed. The purpose of this study was to evaluate temporal trends in volume and utilization of UKA among early-career surgeons and to examine the influence of fellowship training status on utilization of UKA. The American Board of Orthopaedic Surgery (ABOS) Part-II database was queried from 2010 to 2019 to identify candidates who reported ≥1 total knee arthroplasty (TKA) or UKA. Self-reported history of fellowship training experiences was recorded. "High-volume" surgeons were defined as performing ≥7 UKA over the ABOS Part-II collection period. Trends were evaluated with the Cochrane-Armitage test and generalized linear models. From 2010 to 2019, a total of 2,045 candidates (28.1%) reported ≥1 TKA, while 585 candidates (8.0%) reported ≥1 UKA. The number of candidates reporting ≥1 UKA significantly increased (p = 0.001). An increase in UKA volume was observed over the study period (p < 0.001). Rates of utilization of UKA relative to TKA did not change significantly over the study period (p = 0.11). Sixty-three (2.4%) candidates met the study definition for high-volume UKA utilization. UKA procedure volume increased among ABOS Part-II candidates over the study period; however, rates of UKA utilization relative to TKA volume remained unchanged. Increasing volume of UKA performed by early-career surgeons is likely secondary to an increased number of surgeons trained in adult reconstruction. Only 2.4% of candidates who reported performing at least one knee arthroplasty procedure met the threshold for a high-volume UKA practice. Early-career surgeons should remain conscientious of UKA volume in their practice.

Fixed-Bearing Trabecular Metal Total Ankle Arthroplasty Using the Transfibular Approach for End-Stage Ankle Osteoarthritis

This multicenter prospective cohort study assessed the safety and performance of the Trabecular Metal Total Ankle System (TM Ankle; Zimmer) for primary total ankle arthroplasty (TAA).

Long-term National Trends of Arthroscopic Meniscal Repair and Debridement

BACKGROUND

Optimal treatment of meniscal pathology continues to evolve in orthopaedic surgery, with a growing understanding of which patients benefit from which procedure and which patients might be best treated nonsurgically. In 2002, Moseley et al found no difference between arthroscopic procedures, including meniscal debridement and sham surgery, in patients with osteoarthritis of the knee. This called into question the role of routine arthroscopic debridement in these patients. Additionally, an increased interest in understanding and maintaining the function of the meniscus has more recently resulted in a greater focus on meniscal preservation procedures.

STUDY DESIGN

Descriptive epidemiology study.

PURPOSE/HYPOTHESIS

The purpose was to evaluate the trends of arthroscopic meniscal debridement and repair and the characteristics of the patients receiving these treatments, compare the differences in practice between newly trained orthopaedic sports medicine specialists and those of other specialties, and analyze if there are differences in practice by region. It was hypothesized that the American Board of Orthopaedic Surgery (ABOS) database would evaluate practice patterns of recent graduates as a surrogate for current treatment and training and, consequently, demonstrate a decreased rate of meniscal debridement.

METHODS

Data from ABOS Part II examinees from 2001 to 2017 were obtained from the ABOS Case List. Current Procedure Terminology (CPT) codes related to arthroscopic meniscal treatment were selected. The examination year, age of the patient, practice region, and examinee subspecialty were analyzed. Patient age was stratified into 4 groups: <30, 30 to 50, 51 to 65, and >65 years. Examinee subspecialty was stratified into sports medicine and non-sports medicine. Statistical regression analysis was performed.

RESULTS

Between 2001 and 2017, ABOS Part II examinees submitted 131,047 cases with CPT codes 29880 to 29883. Meniscal debridement volume decreased for all age groups during the study period, while repair increased. Sports medicine subspecialists were more likely than their counterparts to perform repair over debridement in patients aged younger than 30 years (P = .0004) and between 30 and 50 years (P = .0005).

CONCLUSION

This study provides insights into arthroscopic meniscal debridement and repair practice trends among ABOS Part II examinees. Meniscal debridement is decreasing and meniscal repair is increasing. Younger patient age and treatment by a sports medicine subspecialty examinee are associated with a higher likelihood of repair over debridement.

Total ankle arthroplasty and ankle arthrodesis in rheumatic disease patients: An analysis of outcomes and complications using the National Inpatient Sample (NIS) database

INTRODUCTION

Rheumatoid arthritis (RA), can manifest as an inflammatory arthropathy in the ankle. As a result, this study sought to examine the role of RA with respect to complications in patients undergoing either total ankle arthroplasty or ankle arthrodesis by utilizing the National Inpatient Sample to assess for correlations.

METHODS

Admissions for TAA and AA were extracted from the National Inpatient Sample using primary ICD-9-CM diagnosis codes. Patients aged 18-65 years with a duration of hospital stay of >3 days and isolated complications were included. Multivariable regression was then performed within matched groups to determine differences.

RESULTS

There was decreased risk of myocardial infarction, pulmonary embolism, surgical site infection, and urinary tract infection in patients with RA. Postoperative development of pneumonia was seen at a higher rate in patients with RA.

CONCLUSION

RA is not associated with a markedly increased complication burden in the appropriately chosen surgical candidate for ankle arthrodesis and ankle arthroplasty.

Trend in Spain in the use of total ankle arthroplasty versus arthrodesis in the period 1997-2017

OBJECTIVE

The main objective of this study is to compare proportionally the incidence of total ankle arthroplasty (TAA) versus ankle arthrodesis and to determine the variables that may have influenced its indication. The secondary objective is to analyse the trend in the use of TAA using a population-based analysis and to compare our results with those reported by national registries in other countries.

MATERIAL AND METHOD

A retrospective review of the Minimum Basic Data Set from 1997-2017 was performed. Subjects were categorised according to surgical procedure. Their temporal evolution was analysed and hospital variables associated with the indication (age, sex, hospital complexity) were identified. In order to compare the trend in Spain with respect to other countries, the information was standardised as number of procedures per 100,000 inhabitants/year and a projection was made for the five-year period 2020-2025.

RESULTS

In the period 1997-2017, 11,669 ankle arthrodesis and 1,049 TAAs were performed. The trend was increasing and significant for both procedures, however, in the last 10 years analysed the proportional trend of TAA decreased significantly. Being female (OR 1.32), being 65 years or older (OR 1.50) and being operated in a complex hospital (OR 1.31) were associated with the indication for a TAA. Compared to other countries, Spain has much lower rates of TAA utilisation, with minimal growth estimated for the year 2025.

CONCLUSION

Although the use of TAA has increased, its growth has been lower than that of ankle arthrodesis and its current trend is proportionally decreasing, with female sex, age≥65 years and the patient being operated in a medium/high complexity hospital being associated with the indication for TAA. Compared with other countries, Spain has much lower rates of use and its projection over the next five years, although increasing, is expected to be minimal.