Trends in total ankle arthroplasty and revisions in the Medicare database

SPECT/CT of Total Ankle Arthroplasty

Use of SPECT/CT (Single Photon Emission Computed Tomography/Computed Tomography) is increasing providing additional information in patients with inconclusive clinical examination and unremarkable imaging findings presenting with chronic pain after total ankle arthroplasty. To differentiate the cause of pain after total ankle arthroplasty can be challenging. SPECT/CT combines structural and metabolic imaging as a hybrid tool leading to higher specificity and overall diagnostic accuracy presumably in cases of gutter impingement, prosthetic loosening, and osteoarthritis of adjacent joints. Moreover, SPECT/CT can complement diagnostic work up in periprosthetic joint infections. Basal tracer enhancement has to be considered for the interpretation of imaging findings.

Early results of combined total ankle total talus replacement in the revision setting

BACKGROUND

Revision of failed total ankle replacement (TAR) is challenging and associated with increased morbidity. Given the increased popularity of TAR in treating end-stage ankle arthritis (ESAA), viable revision options are needed. The objective of this case series is to present a minimum 2-year clinical and radiographic outcomes of patient-specific custom 3D-printed total ankle total talus (TATR) prostheses in this unique subset of patients.

METHODS

19 participants with ESAA and failed primary TAR who underwent TATR by a single surgeon at our institution from 2019 to 2021 were retrospectively identified. All participants were indicated for revision of primary STAR implant (Stryker, Kalamazoo, MI) and underwent replacement with 3D-printed titanium implants based on preoperative CT analysis (Additive Orthopaedics, Little Silver, NJ). Custom components included a mobile-bearing total talus and stemmed tibial system, performed through an anterior approach. Pre- and postoperative patient-reported outcomes were assessed using the Patient Reported Outcomes Measurement Information System (PROMIS). Pre- and postoperative implant alignment was assessed using medial distal tibial angle (MDTA) and tibiotalar angle (TTA) on anteroposterior, and sagittal tibial angle (STA) on lateral weight-bearing plain films.

RESULTS

The average patient age was 60.6 (range, 39-77) years, with an average follow-up of 37.9 (range, 25.3-57.5) months. There was statistically significant improvement in all PROMIS domains. Short-term survivorship was 100%, with two participants (11.0%) requiring reoperation for postoperative complications: one underwent open reduction internal fixation of the tibia for a periprosthetic fracture, and another underwent medial gutter debridement and tarsal tunnel release for recurrent pain. There were no significant differences in pre- versus postoperative radiographic alignment measured by MDTA (89.9 vs 86.4), TTA (89.7 vs 88.1), or STA (85.2 vs 85.3).

CONCLUSION

Custom 3D-printed TATR is a promising option for revision TAR. There was significant short-term improvement in pain and physical function, with excellent short-term survivorship and an acceptable postoperative complication rate.

The INVISION Talar Component in Revision Total Ankle Arthroplasty: Analysis of Early Outcomes

INTRODUCTION

Launched in 2018 for revision total ankle arthroplasty (rTAA), the INVISION talar component addresses subsidence when poor talar bone stock is present. Due to the recency of the market-availability of the INVISION, studies evaluating its efficacy are lacking. This study presents the first analysis of early-term outcomes of patients undergoing rTAA with the INVISION talar component.

METHODS

This was a single-center, retrospective review of 28 patients undergoing rTAA with the INVISION talar component and INBONE II tibial component performed between 2018 and 2022. Data on preoperative characteristics, postoperative complications, secondary procedures, and survivorship were collected. The primary outcome measures were rates of major complications, re-operation, and implant failure. Secondary outcomes included post-operative changes in varus and valgus alignment of the tibia and talus.

RESULTS

The most common secondary procedures performed with rTAA were medial malleolus fixation (n = 22, 78.6%) and gastrocnemius recession (n = 14, 50%). Overall, 10.7% (n = 3) of patients underwent reoperation and 14.3% (n = 4) suffered major complications. Incidence of implant failure was 10.7% (n = 3). All reoperations were caused by infection. Mean varus alignment of the tibia and talus improved from 4.07 degrees and 4.83 degrees to 1.67 degrees and 1.23 degrees, respectively. Mean valgus alignment of the tibia and talus improved from 3.67 degrees and 4.22 degrees to 2.00 degrees and 2.32 degrees, respectively.

CONCLUSIONS

In a series of 28 patients undergoing rTAA with the INVISION talar component, we discovered comparatively low rates of reoperation, major complication, and implant failure (10.7%, 14.3%, and 10.7%). The INVISION system appears to have a reasonable safety profile, but further studies evaluating long-term outcomes are required to assess the efficacy of the INVISION system.

Additional Procedures at the Time of Total Ankle Replacement Do Not Increase Risk of Short-term Complications: A Matched Cohort Analysis

Background

This retrospective cohort study compared short-term complication rates following total ankle arthroplasty (TAA), alone or with concomitant procedures. Secondary independent risk factors were also examined as they related to postoperative outcomes.

Methods

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology (CPT) codes to identify patients who underwent TAA (27702) between 2010 to 2021. Patients were divided into cohorts based on the presence or absence of ancillary procedures. Propensity score matching was employed to account for demographic differences, and statistical analyses were performed to compare short-term complication rates between matched cohorts.

Results

A total of 2225 patients were identified, with 1432 (64.4%) receiving TAA alone and 793 (35.6%) with ancillary procedure(s). After matching, 793 patients were included in each cohort. The ancillary cohort had longer operative times (P < .001) and length of hospital stay (LOS) (P < 0.001). Rates for extended LOS were significantly higher in the ancillary cohort than in the simple cohort (P = .01). No other complications varied significantly between cohorts, including the incidence of any adverse event (AAE). American Society of Anesthesiologists classification of 4 was found to be an independent risk factor for development of AAE (odds ratio [OR] = 1.091, P = .04). Matched subgroup analysis excluding tendon lengthening as a concomitant procedure found that the ancillary cohort still had longer operative time (P < .001) and LOS (P < .05) than patients undergoing simple TAA.

Conclusion

Without significant difference in rates of AAE other than extended LOS, the relative safety of ancillary TAA appears similar to that of TAA alone. Such knowledge can help inform surgical decision-making and assuage safety concerns for patients requiring additional corrective procedures at the time of TAA.

Level of Evidence

Level III, retrospective comparative study.

Revision Total Ankle Arthroplasty Using the INBONE II System

BACKGROUND

The utilization of total ankle arthroplasty (TAA) for managing severe ankle osteoarthritis has become increasingly common, leading to a higher occurrence of revision TAA procedures because of failure of primary TAA. This study aims to examine the clinical results associated with revision TAA using the INBONE II system. Given the growing number of TAA revision procedures and a focus on motion-preserving salvage options, we evaluated our early experience with revision TAA.

METHODS

A retrospective analysis was conducted on a group of 60 presumed noninfected patients who underwent revision TAA with the INBONE II system. Detailed information was collected on patient demographics, implant characteristics, concurrent procedures, and complications. The implant survival was estimated using Kaplan-Meier analysis.

RESULTS

The study revealed high complication rates but generally fair clinical outcomes for revision TAA using the INBONE II system. Complications were observed in 22 patients (36.7%), including persistent pain (n = 6), nerve injury/impingement (n = 5), infection (n = 3), fracture (n = 3), implant failure (n = 3), impaired wound healing (n = 2), and osteolysis (n = 3). The 3-year survivorship rate from reoperation was 92.0% (82.7%-100.0%) whereas the 3-year survivorship rate from major complications was 90.4% (80.8%-100.0%).

CONCLUSION

We report high complication rates but generally fair clinical results for revision TAA utilizing the INBONE II system.

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.

Effect of body mass index on acute postoperative complications following Total Ankle Arthroplasty (TAA)

BACKGROUND

Total ankle arthroplasty (TAA) is an effective treatment for various ankle pathologies, but some concern remains for the high associated complication and failure rates relative to major joint arthroplasty of the hip and knee. Patient body mass index (BMI) is a modifiable and potentially important preoperative variable when evaluating postoperative complications. The purpose of this study is to evaluate the effect of BMI, age and sex on the acute postoperative complication rate after TAA.

METHODS

We retrospectively reviewed adult patients who underwent TAA between 2006 and 2021 from the NSQIP database. Using overweight patients as the reference BMI group, we utilized log-binomial models to estimate risk ratios on outcomes while adjusting for sex and age to investigate whether there were significant adjusted differences in complication rates among the BMI groups.

RESULTS

We found that, relative to overweight patients, there were no statistically significant differences in the risk of acute complications for underweight (BMI < 18.5) (P = .118), healthy weight (18.5≤BMI < 25) (P = .544), obese (30≤BMI < 40) (P = .930), or morbidly obese (BMI < 40) (P = .602) patients who underwent TAA. There were also no statistically significant differences in the risk of acute complications based on age category (P = .482,.824) or sex (P = .440) for TAA. Additionally, there were no significant differences between the BMI groups for either major complications (P = .980) or minor complications (P = .168).

CONCLUSION

Ultimately, we found that BMI, age, and sex did not lead to statistically significant differences in the risk of complications within 30 days postoperatively for TAA, even when stratified by major vs minor complications.

LEVEL OF EVIDENCE

Level III.

Short-Term Outcomes After Bipolar Osteochondral Allograft Transplantation (OCAT) in the Ankle

Treatment options for symptomatic cartilage loss in the ankle are not consistently effective. This study documents initial outcomes for patients undergoing bipolar OCAT in the ankle after advances in tissue preservation, transplantation techniques, and patient management strategies were implemented. Patients were prospectively enrolled into a registry designed to follow outcomes after OCAT in the ankle. Fourteen patients were included for analyses (12 primary OCAT, 2 revision OCAT). Four patients underwent Bipolar OCAT (tibia, talus) and 10 Bipolar+ OCAT (tibia, talus, fibula). Short-term (median follow-up 43, range 13-73 months) success was documented for 13 patients. Radiographic assessments indicated OCA integration and maintenance of joint space in 12 patients. Statistically significant (p < .030) and clinically meaningful improvements in AAOS and VAS pain scores were noted at 3 months, 6 months, 1 year, and 2 years following OCA transplantation when compared to preoperative measures. For patients that were nonadherent to postoperative restriction and rehabilitation protocols, all 1-year postoperative PROs were significantly lower (p < .050) than for patients who were adherent. The successful outcomes documented in 13 of 14 patients in conjunction with significant and clinically meaningful improvements in patient-reported measures of pain and function support OCA transplantation as an appropriate treatment option in indicated patients. These improvements in outcomes were associated with advances in OCA preservation, preimplantation treatment, transplantation techniques, and patient management strategies, suggesting this shift in practice be considered for OCA transplantation in the ankle.

Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty

Background

Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies.

Methods

The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria.

Results

Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria.

Conclusion

This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered.

Level of Evidence

Level IV, review.

The Cost-Effectiveness of Smoking Cessation Programs for Prevention of Wound Complications Following Total Ankle Arthroplasty: A Break-Even Analysis

Background

Tobacco use significantly increases the rate of wound complications in patients undergoing total ankle arthroplasty (TAA). Preoperative optimization through smoking cessation programs significantly minimizes the rate of infection and improves wound healing in arthroplasty procedures. Despite its utility, minimal research has examined the cost-effectiveness of preoperative smoking cessation programs to reduce the need for extracapsular irrigation and debridement (I&D) due to wound complications following TAA.

Methods

The cost of an I&D procedure was obtained from our institution's purchasing records. Baseline wound complication rates among tobacco users who have undergone TAA and smoking cessation program cost were obtained from literature. A break-even economic analysis was performed to determine the absolute risk reduction (ARR) to economically justify the implementation of preoperative smoking cessation programs. Different smoking cessation program and I&D costs were tested to account for variations in each factor. ARR was then used to calculate the number needed to treat (NNT) to prevent a single I&D while remaining cost-effective.

Results

Smoking cessation programs were determined to be economically justified if it prevents 1 I&D surgery out of 8 TAAs among tobacco users (ARR = 12.66%) in the early postoperative period (<30 days). ARR was the same at the literature high (27.3%) and weighted literature average (13.3%) complication rates when using the cost of I&D surgery at our institution ($1757.13) and the literature value for a smoking cessation program ($222.45). Cost-effectiveness was maintained with higher I&D surgery costs and lower costs of smoking cessation treatment.

Conclusion

Our model's input data suggest that the routine use of smoking cessation programs among tobacco users undergoing TAA is cost-effective for risk reduction of I&D surgery in the early postoperative period. This intervention was also found to be economically warranted with higher I&D costs and lower smoking cessation program costs than those found in the literature and at our institution.Level of Evidence: Level III, economic and decision analysis.

Prospective Multicenter Study of Salto Talaris Ankle Arthroplasty With Minimum 4-Year Follow-Up

BACKGROUND

Total ankle arthroplasty (TAA) continues to be investigated as a primary treatment for end-stage ankle arthritis. The objective of this study is to report mid- to long-term results of the Salto Talaris TAA using prospectively collected patient-reported outcomes and implant survival rates with 4- to 13-year follow-up.

METHODS

This was a retrospective study of prospectively collected data from 2 multicenter cohort studies from 3 centers. Three hundred fourteen subjects who received a Salto Talaris TAA from 2005 to 2015 were included in the study. Follow-up ranged 4-13 years following index procedure. Outcomes included 36-Item Short Form Health Survey (SF-36) mental and physical component summary scores, pain scores, and adverse events including additional surgeries, revision, or removal of components.

RESULTS

Significant improvements were seen in pain and physical function scores at 2-year follow-up and were generally maintained through most recent follow-up. The survival rate of the prosthesis was >95% (n = 30/32 at >10 years, n = 272/282 at 4.5-10 years). Thirteen patients (4.1%) underwent revision or removal of their prosthesis. Time to revision ranged from 2 months to 6.5 years following the index procedure. Twenty-two patients (7.0%) had additional surgery that did not involve revision or removal of components.

CONCLUSION

Treatment of end-stage ankle arthritis with this implant provided patients with improved pain and functional outcome scores at mid- to long-term follow-up. The significant improvements reported at 2-4 years appeared to endure through the extended follow-up period.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty

Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.

Fusion after a failed primary total ankle arthroplasty

Aims

When a total ankle arthroplasty (TAA) fails, it can be converted to a fusion or a revision arthroplasty. Despite the increasing numbers of TAAs being undertaken, there is little information in the literature about the management of patients undergoing fusion following a failed TAA. The primary aim of this study was to analyze the survival of fusions following a failed TAA using a large dataset from the National Joint Registry (NJR).

Methods

A data linkage study combined NJR and NHS Digital data. Failure of a TAA was defined as a fusion, revision to a further TAA, or amputation. Life tables and Kaplan-Meier graphs were used to record survival. Cox proportional hazards regression models were fitted to compare the rates of failure.

Results

A total of 131 patients underwent fusion as a salvage procedure following TAA. Their mean age was 65.7 years (SD 10.6) and 73 (55.7%) were male. The mean follow-up was 47.5 months (SD 27.2). The mean time between TAA and fusion was 5.3 years (SD 2.7). Overall, 32 (24.4%) underwent reoperations other than revision and 29 (22.1%) failed. Of these 24 (18.3%) underwent revision of the fusion and five (3.8%) had a below-knee amputation. No patients underwent conversion to a further TAA. Failure usually occurred in the first three postoperative years with one-year survival of fusion being 96.0% (95% confidence interval (CI) 90.7 to 98.3) and three-year survival in 69 patients being 77.5% (95% CI 68.3 to 84.4).

Conclusion

Salvage fusion after a failed TAA shows moderate rates of failure and reoperations. Nearly 25% of patients required revision within three years. This study is an extension of studies using the same methodology reporting the failure rates and risk factors for failure, which have recently been published, and also one reporting the outcome of revision TAA for a failed primary TAA, using the same methodology, which will shortly be published.

Talar component subsidence correlates with periprosthetic osteolysis after total ankle arthroplasty

PURPOSE

This study aimed to investigate the relationship between periprosthetic osteolysis around the talar component and the amount of talar component subsidence after total ankle arthroplasty (TAA).

METHODS

This study included forty patients who underwent TAA with a mean follow-up of 67.5 ± 17.0 months. The patients were divided into two groups based on the amount of osteolysis around the talar component, as measured by computed tomography at the latest clinic visit: none to 2 mm (N group, n = 20) and greater than or equal to 2 mm (O group, n = 20). The average amount of talar component subsidence, clinical outcomes, and complications were compared between the two groups. In the O group, the correlation between osteolysis and talar component subsidence was evaluated.

RESULTS

The average talar component subsidence was significantly different between the N (0.22 ± 0.94 mm) and O groups (2.12 ± 2.28 mm). Five out of 20 ankles in the O group required revision surgery owing to talar component subsidence. The Japanese Society for Surgery of the Foot scores in the N and O groups were significantly different: 93.5 ± 7.7 and 85.3 ± 15.4, respectively. In the O group, we found that osteolysis tended to develop on the lateral side, and the amount of osteolysis was positively correlated with the talar component subsidence (r = 0.59, P = .007).

CONCLUSION

In the O group, a positive correlation between osteolysis and talar component subsidence was found, and five patients required revision surgery.

SPECT/CT of Total Ankle Arthroplasty

Use of SPECT/CT (Single Photon Emission Computed Tomography/Computed Tomography) is increasing providing additional information in patients with inconclusive clinical examination and unremarkable imaging findings presenting with chronic pain after total ankle arthroplasty. To differentiate the cause of pain after total ankle arthroplasty can be challenging. SPECT/CT combines structural and metabolic imaging as a hybrid tool leading to higher specificity and overall diagnostic accuracy presumably in cases of gutter impingement, prosthetic loosening, and osteoarthritis of adjacent joints. Moreover, SPECT/CT can complement diagnostic work up in periprosthetic joint infections. Basal tracer enhancement has to be considered for the interpretation of imaging findings.

Ankle Arthroplasty-Does Preoperative Fixed Equinus Affect Patient-Reported Outcomes

Postoperative sagittal range of motion, in particular degree of dorsiflexion, is critical for satisfactory outcomes in total ankle arthroplasty (TAA). Although there is literature discussing techniques to treat a preoperative fixed equinus we are not aware of any papers presenting patient outcomes. We present patient-reported outcomes for our cohort of patients undergoing TAA with preoperative fixed equinus compared to plantigrade ankles. This is a single surgeon, cohort study of consecutive cases. Cases of primary TAA were identified from a local joint registry which prospectively records Foot and Ankle Outcome Scores (FAOS), Short Form-36 (SF-36), and patient satisfaction. Revision cases or those with inadequate data were excluded. Patients were classified as fixed equinus or neutral based on both preoperative weightbearing lateral radiographs and clinical records. Overall 259 cases were identified, 92 were excluded leaving 167 cases for analysis (mean follow-up 81.7 months), 147 were classified as neutral and 20 fixed equinus. The fixed equinus group were significantly younger (neutral 63.9 vs equinus 52.9, p < .001). Stiffness was the only FAOS domain that was detectibly different at baseline (neutral 36.6 vs equinus 25.6, p = .044). Final FAOS scores, change from baseline and patient satisfaction was the same in all domains for both groups. There was no difference in revision rates. With the numbers available we did not demonstrate a postoperative difference in outcomes for patients with preoperative fixed equinus.

Patient Perceptions of Surgeon Reimbursement in Total Ankle Arthroplasty

INTRODUCTION

The incidence of total ankle arthroplasty (TAA) for ankle osteoarthritis has increased in the Medicare population by approximately 16.37% each year. This study examines the patient perception of orthopedic surgeon reimbursement for TAA by Medicare.

METHODS

A total of 78 patients were surveyed anonymously at 2 foot and ankle clinics within an academic health care setting. The surveys were given anonymously before the patients were seen by an orthopedic surgeon. Surveys were returned to office staff who placed them in a collection box to ensure confidentiality.

RESULTS

The average estimate of how much orthopedic surgeons should be reimbursed for TAA was $19 506 and the average estimate of how much orthopedic surgeons were actually reimbursed was $20 772. Fifty patients believed that orthopedic surgeons were under reimbursed, 9 believed that they were reimbursed appropriately, and 19 were unsure. Demographic variables such as age, sex, education level, income, and insurance status had no significant effect on the results.

CONCLUSIONS

Most patients believed orthopedic surgeons are under reimbursed for TAA and that there is a lack of health care transparency regarding orthopedic reimbursement for TAA by Medicare.Levels of Evidence: Level V: Expert opinion.

Vancomycin Powder Is Highly Cost-Effective in Total Ankle Arthroplasty

Prosthetic joint infection (PJI) is a costly and potentially fatal complication in total ankle arthroplasty (TAA). Some surgeons apply topical vancomycin powder to minimize the risk of infection during TAA procedures. The purpose of our study was to determine the cost-effectiveness of using vancomycin powder to prevent PJI following TAA and to propose an economic model that can be applied by foot and ankle surgeons in their decision to incorporate vancomycin powder in practice. Using our institution's records of the cost of 1 g of topical vancomycin powder, we performed a break-even analysis and calculated the absolute risk reduction and number needed to treat for varying costs of vancomycin powder, PJI infection rates, and costs of TAA revision. Costing $3.06 per gram at our institution, vancomycin powder was determined to be cost-effective in TAA if the PJI rate of 3% decreased by an absolute risk reduction of 0.02% (Number Needed to Treat = 5304). Furthermore, our results indicate that vancomycin powder can be highly cost-effective across a wide range of costs, PJI infection rates, and varying costs of TAA revision. The use of vancomycin powder remained cost-effective even when (1) the price of vancomycin powder was as low as $2.50 to as high as $100.00, (2) infection rates ranged from .05 to 3%, and (3) the cost of the TAA revision procedure ranged from $1000 to $10 000.Levels of Evidence: IV.

Analysis of Baseline Characteristics, Length of Stay, Cost of Care, Complications and Subgroup Analysis of Patients Undergoing Total Ankle Arthroplasty-A Large Database Study

Although total ankle arthroplasty (TAA) is becoming a progressively common procedure with a reported 10-fold increase in its prevalence over the past 2 decades; there is still limited large-scale data regarding its overall outcome. Using the National Inpatient Sample (NIS) database, patients who underwent TAA between 2016 and 2019 were identified (ICD-10 CMP code). Data regarding demographic details, co-morbidities, geographic locations of procedure, hospital stay, expenditure incurred, and complications encountered were analyzed. Additionally, a comprehensive subgroup analysis was performed to evaluate the impact of multiple preoperative variables (including gender, diabetes, obesity, CKD and tobacco abuse) on the patient outcome. Overall, 5087 patients (mean age: 65.1 years, 54% males, 85% Caucasians, 75% from large metropolitan regions) underwent TAA. Eighty eight percent of patients were discharged to home; and the mean length of hospital stay and hospital-related expenditure were 1.7 ± 1.41 days and $92,304.5 ± 50,794.1, respectively. The overall complication rate was 8.39% {commonest medical complications: anemia [131 (2.6%) patients) and acute renal failure [37 (0.7%) patients]; commonest local complication: periprosthetic mechanical adversities [90 (1.7%) patients]}. Female and CKD patients demonstrated significantly higher risks of medical (female: p = .003; CKD: p < .001) and surgical (female: p = .005; CKD: p < .019) complications; while obesity substantially enhanced the risk of medical adversities (p < .001). Based on our study, we could conclude that the rates of TAA in the United States are on the rise, especially in regions with population greater than 250,000. TAA is a safe procedure with relatively low complication rates. The complications and hospital-associated expenditure seem to vary between different patient subgroups.

How long do ankle arthroplasties last?

Despite the increasing numbers of ankle arthroplasties, there are limited studies on their survival and comparisons between different implants. The primary aim of this study was to determine the failure rates of primary ankle arthroplasties commonly used in the UK. A data linkage study combined National Joint Registry (NJR) data and NHS Digital data. The primary outcome of failure was defined as the removal or exchange of any components of the implanted device. Life tables and Kaplan-Meier survival charts were used to illustrate survivorship. Cox proportional hazards regression models were fitted to compare failure rates between 1 April 2010 and 31 December 2018. Overall, 5,562 primary ankle arthroplasties were recorded in the NJR. Linked data show a one-year survivorship of 98.8% (95% confidence interval (CI) 98.4% to 99.0%), five-year survival in 2,725 patients of 90.2% (95% CI 89.2% to 91.1%), and ten-year survival in 199 patients of 86.2% (95% CI 84.6% to 87.6%). The five-year survival for fixed-bearing implants was 94.3% (95% CI 91.3% to 96.3%) compared to 89.4% (95% CI 88.3% to 90.4%) for mobile-bearing implants. A Cox regression model for all implants with over 100 implantations using the implant with the best survivorship (Infinity) as the reference, only the STAR (hazard ratio (HR) 1.60 (95% CI 0.87 to 2.96)) and INBONE (HR 0.38 (95% CI 0.05 to 2.84)) did not demonstrate worse survival at three and five years. Ankle arthroplasties in the UK have a five-year survival rate of 90.2%, which is lower than recorded on the NJR, because we have shown that approximately one-third of ankle arthroplasty failures are not reported to the NJR. There are statistically significant differences in survival between different implants. Fixed-bearing implants appear to demonstrate higher survivorship than mobile-bearing implants.

Preoperative Hypoalbuminemia Not Associated With Total Ankle Arthroplasty Outcomes

BACKGROUND

This study aims to investigate the effect of hypoalbuminemia on the rates of 30-day complication, readmission, and reoperation following total ankle arthroplasty (TAA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2007 to 2019 to identify 710 TAA patients. Patients were then stratified into normal (n = 673) or low (n = 37) albumin groups. Demographics, medical comorbidities, concomitant procedures, hospital length of stay, and 30-day complication, readmission, and reoperation rates were compared between groups. Preoperative serum albumin level was also used as a continuous variable when analyzing postoperative outcomes.

RESULTS

The overall cohort was predominantly male (51.5%), and the mean age was 65.02 (range, 45-87) years. We found there to be no statistically significant difference in demographics between cohorts. However, hypoalbuminemia patients were significantly more likely to use long-term steroids for a chronic condition (normal = 6.1%, low = 18.9%; P = .009). Additionally, there was no difference in 30-day complication (normal = 3.0%, low = 0.0%; P = .618), readmission (normal = 2.4%, low = 0.0%; P = .632), and reoperation (normal = 1.0%, low = 0.0%; P = 1.000) rates between groups.

CONCLUSION

The results of this study show that malnourished patients are not at an increased risk of 30-day complication, readmission, or reoperation following TAA despite having a worse preoperative comorbidity profile.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Complications Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Primary Ankle Osteoarthritis

INTRODUCTION

There are minimal data comparing complications between ankle arthrodesis (AA) versus total ankle arthroplasty (TAR) for operative management of primary osteoarthritis (OA). This study aimed to compare outcomes following AA versus TAR for primary ankle OA using a large patient database.

METHODS

Patients who received AA or TAR for primary ankle OA from 2010 to 2019 were queried from PearlDiver. Rates of common joint complications were compared at 90 days, 1 year, and 2 years postoperatively using multivariable logistic regression.

RESULTS

A total of 1136 (67%) patients received AA and 584 (33%) patients underwent TAR. Patients that received AA exhibited significantly higher rates of at least one common joint complication at 90 days (19.3% vs 12.6%; odds ratio [OR] 1.69), 1 year (25.6% vs 15.0%; OR 2.00), and 2 years (26.9% vs 16.2%; OR 1.91) postoperatively. This included higher rates of adjacent fusion or osteotomy procedures, periprosthetic fractures, and hardware removal at each postoperative follow-up (all P < .05). Rates of prosthetic joint infection were comparable at 2 years postoperatively (4.3% vs 4.2%; OR 0.91).

CONCLUSION

The AA cohort exhibited higher rates of postoperative joint complications in the short and medium-term, namely, subsequent fusions or osteotomies, periprosthetic fractures, and hardware removal.

LEVELS OF EVIDENCE

Level III.

Complications, Reoperations, and Patient-Reported Outcomes Following a 2-Stage Revision Total Ankle Arthroplasty for Chronic Periprosthetic Joint Infections

BACKGROUND

As total ankle arthroplasty (TAA) becomes more common, chronic periprosthetic joint infections (PJIs) will be encountered more frequently. No studies have reported on patient-reported outcomes following a 2-stage revision procedure for a chronic PJI after a TAA. The primary purpose of this study was to investigate postoperative clinical outcomes at a minimum of 2 years following a 2-stage revision TAA for chronic PJI.

METHODS

Patients who underwent a 2-stage revision TAA for a chronic PJI (>4 weeks after a primary TAA) between January 2010 and December 2019 were eligible to be included in this study. Chronic PJI was defined as a sinus tract that directly communicated with the prosthesis or the same organism identified in ≥2 synovial fluid samples. Twelve patients were eligible to be included in this case series. One patient died prior to 2-year follow-up, which left 11 patients available for analysis. All 11 patients underwent reimplantation. The data were found not to be normally distributed; therefore, medians and interquartile ranges (IQRs) were reported.

RESULTS

At a median of 3.0 years (IQR 2.0-4.0 years) following the second stage of their revision arthroplasty, the median Foot and Ankle Ability Measure (FAAM) Activities of Daily Living and Sports scores were 60.7 (IQR 52.4, 79.8) and 31.3 (IQR 9.4, 40.6), respectively. At final follow-up, 10 patients (90.9%) were ambulating with a TAA in place. Seven patients (63.6%) required a reoperation including 1 patient who underwent a below-knee amputation.

CONCLUSION

Our study suggests that a 2-stage revision TAA may be an option for patients with a chronic PJI. However, patients who undergo a 2-stage revision TAA for a chronic PJI have lower than previously published 2-year FAAM scores and a high rate of reoperation.

LEVEL OF EVIDENCE

Level IV, case series.

97 HINTEGRA ankle prostheses: Results and survival at more than 5 years' follow-up

BACKGROUND

In Europe, fixed-bearing implants predominate again in total ankle replacement (TAR). The present single-center single-surgeon study assesses the Hintegra® mobile-bearing implant (NEWDEAL).

METHODS

Between November 2008 and November 2015, 97 Hintegra® were implanted in 94 patients: mean age, 62.4±10.9 years (26-83); 59% (57/97) male; normal mean body-mass index (BMI), 27.5 ± 4.3 kg/m². Indications mainly comprised posttraumatic (40.2%), instability (29.9%) and primary osteoarthritis (16.5%). 17.5% of patients had prior surgery during the previous 6 months (9 fusions, 8 ligament reconstructions, and 4 osteotomies); in 59.8%, other procedures were associated to TAR. Functional, clinical and radiological follow-up was conducted at 1 year, 2 years and last follow-up (>5 years).

RESULTS

Ninety-four TARs were analyzed at a mean 81 ± 21.6 months (19-124). Revision-free survival was 76% (95% confidence interval (95%CI): 0.66-0.8), and explantation-free survival 92% (95%CI: 0.85-1) with 10 cases of curettage and 5 explantations. Mean AOFAS score improved from 41.8 ± 12.5 (21-69) to 77.5 ± 16.5 (24-100) up (p < 0.001); 75% of patients had no or only mild pain (p < 0.001). Clinical ranges of motion were 8.0 ± 7.1° dorsiflexion (p < 0.001) and 35.1 ± 9.4° plantar flexion (preoperatively, 34.1 ± 7.9°) (p = 0.71). Radiologically, tibial components were well-positioned; 87% of talar components were well-centered. Global ankle range of motion was 23.5 ± 10.2° (5-48) (p = 0.17). 54.6% of TARs showed posterior tibial calcification at follow-up. Risk of severe cyst (>1 cm) on CT was 36% (95%CI: 23-47) at a mean 77 ± 21.9 months (18-123).

CONCLUSION

Hintegra® TAR incurred a low risk of revision, and is a reliable option for ankle osteoarthritis.

LEVEL OF EVIDENCE

IV.

Consumer Interest in Total Ankle Replacements Over the Last 10 Years: A Google Trends™ Analysis From 2009 to 2019

With an aging population, the incidence of osteoarthritis (OA) continues to grow. After exhausting conservative therapy for many forms of OA, patients regularly opt for surgical intervention in the form of total joint replacement surgery. One form, total ankle replacement, has continued to gain favorability in the medical community. Improved implant design and surgical technique have enabled success rates of total ankle replacements to approach those of the hip and knee. As a new and improving therapy to address end-stage ankle OA, knowledge of patient-interest has yet to be determined. We used search inquiry data for the keywords "ankle arthritis" "ankle replacement" and "ankle fusion" available from Google Trends™ to identify trends in patient and geographic interest from 2009 to 2019. Search inquiries significantly increased for all keywords over time (p < .001). Trend analysis over this 10-year period revealed a strong correlation for ankle arthritis (0.88) and ankle replacement (0.76). Moreover, the correlation between "ankle arthritis" and "ankle replacement" was strong (0.83) during this period. The geographic distribution of these search terms showed the greatest increase in interest for the keywords "ankle arthritis" "ankle replacement" and "ankle fusion" in Arizona, New York, and Virginia respectively. Results of this study illustrate a similar increasing patient interest in ankle arthritis and ankle replacements. This data can be used effectively identify, educate, and treat populations interested in ankle replacements. To the best of our knowledge, this is the first study to utilize Google Trends™ to analyze patient interest in foot and ankle surgery.

Home and Outpatient Physical Therapy Utilization Following Total Ankle Replacement

Background

Physical therapy (PT) following total ankle replacement (TAR) is often considered, but guidelines for its use are not standardized. Although patient factors may dictate recommendations, this retrospective cohort study aims to characterize baseline utilization practices to set the stage for establishing generalizable recommendations.

Methods

TAR patients were identified from the 2010-2019 M91 Ortho PearlDiver data set based on administrative coding. Patient factors were extracted, including age, sex, Elixhauser Comorbidity Index (ECI), region of the country in which patients' surgery was performed (Midwest, Northeast, South, West), and insurance plan (commercial, Medicaid, Medicare). The incidence, timing, and frequency of home or outpatient PT utilization in the 90 days following TAR were identified. Inpatient PT was not captured. Univariate and multivariate logistic regression analyses allowed identification of predictive factors for PT utilization.

Results

Of 5412 TAR patients identified, postoperative PT services were used by 2453 (45.3%). Most PT was outpatient (38.3% of the study population) compared to home (4.1% of the study population). Weekly utilization of PT was greatest in the first week following surgery (17.7% of PT visits) and thereafter followed a roughly bell-shaped curve, with utilization greatest at 7 weeks following surgery (14.9% of PT visits).Independent predictors of PT utilization following TAR included having surgery performed in the Midwest (relative to the South, OR 1.37, P < .0001), Northeast (OR 1.20, P = .0217), or West (OR 1.26, P < .0021) and having commercial (relative to Medicare, OR 1.87, P < .0001) or Medicaid insurance (OR 1.46, P = .0239).

Conclusion

Of 5412 TAR patients, 42.5% used PT within 90 days of surgery. PT utilization was highest in the first and seventh weeks following surgery, and demographic predictors of PT use were defined. Through identification of timing and predictors of PT utilization following TAR, PT care pathways may be better defined.

Level of Evidence

Level III, retrospective cohort study.

Clinical and Radiographic Outcomes of Revision Total Ankle Arthroplasty Using the INBONE II Prosthesis

BACKGROUND

The literature on the outcome of revision total ankle arthroplasty (TAA) remains limited. In this study, we aimed to report the clinical and radiographic outcomes of revision TAA at a high-volume center in the United Kingdom.

METHODS

This study was a retrospective review of 28 patients who underwent 29 revision TAAs using the INBONE II Total Ankle System (Wright Medical Technology/Stryker). Demographic, radiographic, and patient-reported outcome measure data were analyzed.

RESULTS

The mean duration from primary TAA to revision was 87.5 months (range, 16 to 223 months). The main indication for the revision was aseptic loosening after the primary TAA (83%). Additional procedures were required in 76% of ankles. At a mean follow-up of 40 months (range, 24 to 60 months), the infection rate was 7%, the reoperation rate was 7%, and the implant survival rate was 97%. A significant postoperative improvement in the radiographic component alignment measures was observed. The subsidence, loosening, and heterotopic ossification rates in this study were comparable with those in other reports and did not influence the clinical outcome. A significant improvement was observed in the Manchester-Oxford Foot Questionnaire (MOXFQ) in all domains and the EuroQol-5 Dimensions (EQ-5D) in 3 domains at 24 months postoperatively.

CONCLUSIONS

Revision TAA using the INBONE II prosthesis was associated with good short-term survival and improvement in postoperative scores at 2 years. Maintenance of the postoperatively improved alignment was documented at the follow-up. The results of this study support the notion that revision TAA is a satisfactory option for failed primary TAA.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Preoperative Depression Influences Outcomes Following Total Ankle Arthroplasty

INTRODUCTION

Total ankle arthroplasty (TAA) is increasing in incidence. While preoperative depression is known to affect outcomes following other procedures, its effect on outcomes following TAA are unknown. Therefore, the purpose of this study was to investigate this relationship.

METHODS

This is a retrospective cohort study using the Nationwide Readmission Database (NRD). All patients undergoing TAA were included. Two cohorts (those with and without preoperative depression) were created. Logistic regression was then performed to assess the contribution of a preoperative diagnosis of depression on rates of 90-day complications, while controlling for patient demographic and comorbid data.

RESULTS

Overall, 8047 patients were included, of whom, 11.4% (918) were depressed. Compared to patients without depression, patients with depression had increased odds of the following: nonhome discharge (OR 1.61, 95% CI 1.31-1.98), extended length of stay (>2 days; OR 1.34, 95% CI 1.15-1.57), prosthetic complication (OR 1.39, 95% CI 1.10-1.74), wound complication (OR 1.59, 95% CI 1.11-2.29), prosthetic joint infection (OR 1.82, 95% CI 1.06-3.15), superficial surgical site infection (OR 1.62, 95% CI 1.02-2.58), and medical complication (OR 1.32, 95% CI 1.03-1.68).

DISCUSSION

Depression in patients undergoing TAA is common and is associated with increased health care utilization and complications following surgery. The modifiability of depression should be investigated with future studies.

LEVELS OF EVIDENCE

Prognostic, Level III: Comparative study.

Utilization Trends of Total Ankle Arthroplasty and Ankle Fusion for Tibiotalar Osteoarthritis: A Nationwide Analysis of the United States Population

Introduction: Studies evaluating utilization and trends of total ankle arthroplasty (TAA) and ankle fusion (AF) are sparse. The purpose of this study was to use a nationwide administrative claims database to compare baseline demographics between TAA and ankle arthrodesis and to determine whether patients who had a TAA have increased rates of: (1) utilization, (2) in-hospital length of stay (LOS), and (3) costs of care. Methods: PearlDiver, a nationwide claims database was queried from 2005 to December 2013 for all patients who underwent primary TAA or AF for the treatment of osteoarthritis of the ankle and foot. Baseline demographics of age, sex, geographic distribution, and the prevalence of comorbidities comprising the Elixhauser comorbidity index (ECI) were compared between patients who had TAA and AF. Linear regression was used to compare differences in utilization and in-hospital LOS between the 2 cohorts during the study interval. Annual charges and reimbursement rates for TAA were assessed during the study period. A P value less than .05 was considered to be statistically significant. Results: A total of 21 433 patients undergoing primary TAA (n = 7126) and AF (n = 14 307) were included. Patients undergoing TAA had significantly greater ECI driven by arrythmias, congestive heart failure, diabetes mellitus, electrolyte/fluid disorders, iron deficiency anemia than patients undergoing AF (P < .001). From 2005 to 2013, TAA utilization increased from 21.5% to 49.4% of procedures (P < .0001). There was reduced in-hospital LOS over the time interval for patients with TAA compared with AF (2.15 days vs. 3.11 days, P < .0001). Total ankle arthroplasty reimbursements remained stable while charges per patient increased significantly from $40 203.48 in 2005 to doubling by the end of 2013 to $86 208.59 (P < .0001). Conclusion: This study demonstrated increased use of TAA compared to AF showing decreased in-hospital LOS and increased cost of care with stagnant reimbursement rates.Level of Evidence: Level III.

Projections and Epidemiology of Total Ankle and Revision Total Ankle Arthroplasty in the United States to 2030

Background: Total ankle arthroplasty (TAA) utilization is increasing in the United States. As the incidence of this procedure grows, it is important for providers to understand the future projections for ankle arthroplasty and more importantly revision total ankle arthroplasty (rTAA). Methods: The National Inpatient Sample (USA) was queried from 2005 to 2017 for all TAA and rTAA. Poisson and linear regression analysis was performed to project annual incidence of TAA and rTAA to 2030, with subgroup analyses on septic rTAA. Results: There were 5315 TAAs performed in 2017, a 564% (P < .001) increase when compared with the TAAs performed in 2005. From 2017 to 2030, the incidence of TAAs is projected to increase from 110% to 796% (P < .001). There were 1170 rTAAs performed in 2017, a 155% (P < .001) increase when compared with rTAAs performed in 2005. There was a 256% increase in the incidence of septic rTAAs from 2005 to 2017 with a projected increase between 22% and 120% by 2030. Conclusions: The incidence of both TAAs and rTAAs is projected to significantly increase over the next decade. Given the known risk factors of TAA and rTAA, these findings reinforce the need for thoughtful consideration when selecting patients for TAA.

The Most-Cited Ankle Arthroplasty Implant Articles

Background:

Citation analysis is a useful way of evaluating the impact, importance, and merit of articles within a medical specialty. Our study identified and analyzed the most-cited articles on ankle arthroplasty implants to evaluate their importance in the field of ankle arthroplasty research.

Methods:

Using the keywords “ankle arthroplasty” and “ankle replacement” and the search period 1970-2021, we found 3728 articles on ankle arthroplasty implants in the Scopus, Web of Science, and MEDLINE/PubMed databases. We included original articles, reviews, clinical trials, and case reports in the study. We retrieved the 50 most-cited articles published during the time frame and then screened them for studies of specific ankle arthroplasty implants and their postoperative outcomes. We also recorded and analyzed the articles’ subjects, authorship, journals, countries of origin, and years of publication.

Results:

The 50 most-cited articles were published between 1983 and 2014, with the majority (33) published between 2000 and 2010. They generated 9012 citations in the literature. The most-cited study accounted for 497 citations; the mean number of citations per article was 180.24 ± 76.24. Twenty-three (46%) of the articles addressed postoperative outcomes following a specific type of arthroplasty implant. Arthroplasty implant studies accounted for 4726 citations, or 52.4% of the citations of the 50 articles. The most frequently studied arthroplasty implant was STAR (15), followed by Agility (7), Buechel Pappas (5), and Salto (4). STAR accounted for 3311 citations, or 37% of the total citations of the 50 articles.

Conclusion:

Ankle arthroplasty research has made great progress in the past 2 decades, particularly in the area of postoperative outcomes of specific ankle implants, but continued research and publication on additional arthroplasty implants should become a priority.

Level of Evidence:

Level V, Review Article.

Ankle plantar flexor muscle performance and patient reported outcomes in people following total ankle arthroplasty

BACKGROUND

The purpose of this study was to prospectively evaluate ankle power generation during gait in people with total ankle arthroplasty, and examine the relationships between postoperative plantar flexor strength, ankle power, and patient outcomes.

METHODS

Nineteen people with end-stage ankle arthritis who received a total ankle arthroplasty and 19 healthy matched controls participated in this case-control study. Patient reported outcomes included a region specific measure of foot function and a generic measure of physical function. Gait speed was recorded with the 6-min walk test. Isokinetic plantar flexor strength was measured with an instrumented dynamometer. Motion capture and force plate data were used to calculate peak ankle power generation during walking. Paired or independent t-tests were used to compare ankle power across time and between groups, respectively. Bivariate correlations were performed to examine the interplay of postoperative strength, ankle power, gait speed, and patient reported outcomes.

FINDINGS

Ankle power was not different between the preoperative and 6-month postoperative time points (d = 0.20). Six-month postoperative ankle power was less than controls (d = 1.32). Strength, ankle power, and gait speed were directly correlated in the patient group 6-months postoperatively (r or ρ ≥ 0.47). Six-month postoperative strength and ankle power were directly correlated to select 2-year patient reported outcomes (both ρ = 0.54).

INTERPRETATION

Lower than normal 6-month postoperative ankle power, which was correlated to strength, gait speed, and longer-term patient reported outcomes, suggests efforts toward improving ankle plantar flexor muscle performance may improve patient outcomes.

Radiological assessments and clinical results of intra-articular osteotomy for traumatic osteoarthritis of the ankle

INTRODUCTION

Traumatic osteoarthritis of the ankle joint caused after malleolar fractures of the ankle and tibial plafond fractures are frequently observed in comparatively young and highly active patients. Since the ankle movement in these patients is in general, comparatively favorable, orthopedists may sometimes have difficulty in deciding on a treatment policy. In our department, when treating traumatic osteoarthritis patients having a movable range within their ankle joints, we proactively applied distal tibial oblique osteotomy (DTOO) developed by Dr. Teramoto in 1994 or intra-articular osteotomy developed based on DTOO concepts such as distal tibial intra-articular osteotomy (DTIO) and distal fibular oblique osteotomy (DFOO).The objectives of the current study are to radiologically assess the ankle joint after intra-articular osteotomy for traumatic ankle osteoarthritis and evaluate the change in configuration of the ankle joint. This study summarizes the clinical results of intra-articular osteotomy obtained through the above-mentioned study.

PATIENTS AND METHODS

The subjects of this study were 20 patients diagnosed with traumatic osteoarthritis who were surgically treated for a total of 20 ankles. All patients underwent treatment with intra-articular osteotomy and were evaluated retrospectively for the following parameters: surgical procedure, fixation devices, clinical results based on the Japanese Society for Surgery of the Foot ankle/hindfoot scale (hereafter, JSSF scale) and post-operative adverse events. They were also assessed radiologically with pre- and post-operative anterior-posterior (AP) and lateral weight-bearing ankle radiographs.

RESULTS

The 20 patients consisted of 12 males and 8 females. The median age at surgery was 49 years old (range 14 - 87 years old) and the average follow-up period was 42 months (range 19 to 121 months). DTOO was applied to 10 cases, DFOO to 2 cases, DTOO and DFOO to 2 cases, medial-distal tibial intra-articular osteotomy (M-DTIO) and DFOO to 1 case, lateral-distal tibial intra-articular osteotomy (L-DTIO) and DFOO to 3 cases, M-DTIO followed by DTOO and DFOO to 1 case, and DTOO followed by low tibial osteotomy (LTO) to 1 case. Fixation devices utilized included circular external fixator for 15 cases, locking compression plate (LCP) to 3 cases, LCP and Kirschner-wire (K-wire) to 1 case, and screw and K-wire to 1 case. Radiological assessment revealed significant changes in the following parameters after surgery: tibial ankle surface angle (TAS, P= 0.0203), tibiotalar surface angle (TTS, P= 0.0021), medial malleolar angle (MMA, P= 0.0217), empirical axis (EA, P= 0.0019), fibular angle (FA, P= 0.0002), talar tilt angle (TTA, P= 0.0374), and tibial lateral surface angle (TLS, P= 0.0279). The JSSF scale also improved significantly after surgery (pre-operative JSSF scale: 51.1±11.0, post-operative JSSF scale: 89.2±8.2), p=0.0001.

CONCLUSION

Intra-articular osteotomy may change the radiological configuration of the ankle in a weight-bearing state. The present study showed very good short-term clinical results. Intra-articular osteotomy can prove a viable surgical option applicable for treatment of patients with traumatic ankle osteoarthritis having a reasonable range of motion within their ankle joints.

Safety and Effectiveness of Outpatient Total Ankle Arthroplasty

BACKGROUND

Total ankle arthroplasty (TAA) is a surgical procedure commonly reserved for patients suffering from symptomatic end-stage ankle arthritis. As the number of TAAs increases, so does the associated economic burden. Given these economic constraints, there has been interest in the feasibility of outpatient TAA. The purpose of this study is to evaluate the safety, efficacy, and satisfaction of patients undergoing outpatient TAA.

METHODS

This is a retrospective case series of consecutive patients who underwent outpatient TAA from July 2018 to June 2019. Inclusion criteria included any patient undergoing a primary TAA in the outpatient setting. This was defined as discharge on the same day of surgery or within 12 hours of surgery. All surgeries were completed by a single experienced surgeon through an anterior approach using the Cadence Total Ankle System. Prior to surgery, all patients received a popliteal nerve block. Patients were then discharged home with oral analgesic and a popliteal nerve catheter, which they removed after 48 hours. The primary outcome of interest was postoperative pain control, which was measured using a numeric scale. Secondary outcomes included complication rate, readmission rate, and patient satisfaction. A review of the current literature was then completed to supplement our results.

RESULTS

In total, 41 patients were included in our analysis. In terms of the primary outcome, the average numeric scale score was 1.98, indicating excellent pain control. Additionally, nearly all 41 patients stated they were very satisfied with their postoperative pain control regimen. In terms of secondary outcomes, the majority of patients stated they were satisfied with discharge on the same day as surgery. There were no readmissions or major complications in our outpatient TAA cohort. When asked if they would recommend the care they experienced to a friend with the same condition, 95% of patients said that they would recommend this care pathway. Our literature review included 5 original studies, which were all retrospective level IV studies. These studies uniformly demonstrated the safety and efficacy of outpatient TAA.

CONCLUSIONS

The results of our study demonstrate the outpatient TAA is associated with excellent pain control using a multidisciplinary pain approach. The use of standardized outpatient postoperative pathways was effective in preventing readmissions and complications, while still resulting in high patient satisfaction scores. A review of the literature complemented our results, as there are largely no significant differences between outpatient and inpatient TAA.Level of Evidence: Level IV, case series.

Preoperative Guidance With Weight-Bearing Computed Tomography and Patient-Specific Instrumentation in Foot and Ankle Surgery

The use of preoperative and intraoperative guidance in foot and ankle surgery has grown substantially in recent years. Weight-bearing computed tomography (WBCT) and patient-specific instrumentation (PSI) are used in total ankle arthroplasty (TAA) to achieve precise bone cutting and implant positioning, and intraoperative 3-dimensional (3D) imaging has been used to reduce complications and improve clinical outcomes in other foot and ankle surgical procedures. This narrative review of the literature focuses on the evidence supporting the use of WBCT and PSI in TAA and looks at other promising technologies used to guide foot and ankle surgery.

A Prospective Cohort Study Comparing Functional Outcomes of Primary and Revision Ankle Replacements

BACKGROUND

The number of ankle and revision ankle replacements performed is increasing. There is limited research into functional outcomes, especially in revision ankle replacements. The primary aim of this cohort study was to determine the functional improvements following primary and revision ankle replacements and compare which gave the greatest improvement in functional scores.

METHODS

A single-center prospective cohort study was undertaken between 2015 and 2018. All patients were followed up for a minimum of 2 years. Patients undertook a preoperative and 2-year Manchester Oxford Foot Questionnaire (MoxFQ) score. The Mann Whitney test was undertaken.

RESULTS

A total of 33 primary and 23 revision ankle replacements were performed between 2015 and 2018. The mean age was 69.3 years for primary replacements and 64.7 years for revision replacements. All primary replacements were the Infinity ankle replacement. Revision replacements were either the Inbone II or Invision. The indication for revision was 9 aseptic loosening, 6 infections, 5 cysts, and 3 malposition. Seventeen were performed as a single stage and 6 as a 2-stage revision. The overall MoxFQ improved by a mean of 48.8 for primaries and 20.2 for revisions (P = .024). The walking/standing domain improved by 57.5 for primaries and 22.5 for revisions (P = .016), the pain score improved by 43.0 and 32.3 (P = .009), and the social interaction improved by 40.0 and 11.7 (P = .128).

CONCLUSION

Both primary and revision ankle replacements result in improved functional scores. In this relatively small cohort with the implants used, primary ankle replacements though have a significantly greater improvement in functional scores compared to revision ankle replacements.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Comparison of Patient Demographics and Utilization Trends of Robotic-Assisted and Non-Robotic-Assisted Unicompartmental Knee Arthroplasty

Robotic-assisted unicompartmental knee arthroplasty (RAUKA) is an emerging area of interest. The purpose of this study was to compare (1) different patient demographic profiles; (2) annual primary and revision utilization rates; (3) risk factors for revision procedures; and (4) survivorship between RAUKA and manual UKA (MUKA). Using the PearlDiver database, patients who underwent RAUKA or MUKA between 2005 and 2014 within the Medicare database were identified, yielding a total of 35,061 patients (RAUKA = 13,617; manual = 21,444). Patient demographics (age, gender, comorbidities, Charlson-Comorbidity Index, and geographic region) were compared between cohorts. Annual primary and revision utilization rates as well as risk factors for revision procedures were also compared. Kaplan-Meier survivorship was also calculated. The Pearson χ² test was used to test for significance in patient demographics, whereas the Welch t-test was used to compare the incidence of revisions as well as the revision burden (proportion of revisions to total sum of primary and revision procedures). Multivariate binomial logistic regression analysis was performed to compare risk factors for revision procedures. There were statistically significant differences in RAUKA versus MUKA patients with respect to age (p < 0.001), gender (p < 0.001), and region (p < 0.001). RAUKA procedures performed increased over 12-fold compared with manual, which increased only 4.5-fold. RAUKA procedures had significantly lower revision incidence (0.99 vs. 4.24%, p = 0.003) and revision burden (0.91 vs. 4.23%, p = 0.005) compared with manuals. For patients undergoing RAUKA, normal (19-24 kg/m²) and obese (30-39 kg/m²) body mass index (p < 0.05), congestive heart failure (p = 0.004), hypothyroidism (p < 0.001), opioid dependency (p = 0.002), and rheumatoid arthritis (p < 0.001) were risk factors for a revision procedure. Kaplan-Meier survival curve 3 years following the index procedure to all-cause revisions demonstrated that RAUKA patients maintained nearly 100% survivorship compared with manual patients who had 97.5% survivorship. The data demonstrate increased utilization of RAUKA in the United States. The current data indicated that RAUKA has significantly lower revision rates and improved survivorship compared with patients undergoing non-RAUKA within Medicare patients.

Infinity ankle arthroplasty with traditional instrumentation and PSI prophecy system: preliminary results

Ankle arthrodesis has been considered the surgical Gold Standard for advanced ankle arthritis; prosthetic replacement of the tibio-talar joint played a secondary role.The introduction of last generation ankle prostheses lead to better outcome and a lower rate of complication. PSI represents the most recent innovations introduced on the market of ankle arthroplasty:PSI is proposed as a surgical technique capable of making ankle arthroplasty more accurate and more reproducible compared to standard referencing guides Aim of the study is to report early clinical and radiographic outcomes obtained from a single surgeon experience by implanting the same ankle prosthesis using a standard (STD) or a PSI instrumentation Unlike no difference in the average increment of normalized sub score related to function in each group (PSI vs STD), the analysis of normalized pain sub score pointed out a greater average improvement in the PSI group(+75%)compared to the STD group(+62%);this result has been adovacated to the absence of post operative gutter impingement syndrome in the PSI group compared to the STD referencing group. The analysis of radiographic angles revealed a more accurate and reproducible positioning of the components in the PSI group; ankle arthroplasty performed with PSI reported a reduction of both surgical times and the need of intraop.fluoroscopy. PSI ankle arthroplasty achived more accurate and reproducible clinical and radiographic results compared to STD instrumentation;long-term follow-up are needed to demonstrate whether a better positioning of the implant is associated with an increased survival of the prosthesis and therefore justifies the additional costs of PSI.

Trends in Primary Proximal Interphalangeal Joint System and Revisions for Osteoarthritis of the Hand in the Medicare Database

Background: Proximal interphalangeal arthroplasty (PIPA) has been indicated for patients suffering from osteoarthritis (OA) or rheumatoid arthritis of the hand. Although there is extensive literature showing the outcomes of PIPA, there is paucity in the literature regarding trends of PIPA in patients with OA of the hand. The purpose of this study was to determine annual primary utilization and revision PIPA trends within the Medicare population with the use of an administrative database. Methods: A retrospective query was performed using the Medicare Standard Analytical Files from the PearlDiver database. Patients undergoing primary and revision PIPA with hand OA were queried using International Classification of Disease, Ninth Revision, and Current Procedural Terminology coding. Primary outcomes analyzed included annual and revision utilization of PIPA and demographic comparison of age, gender, and geographic location. Statistical analysis was primarily descriptive. An α value less than 0.05 was considered statistically significant. Results: The query returned 10 191 patients who underwent primary and revision PIPA between 2005 and 2013. Calculated annual growth rate for primary and revision PIPA was 2.40% and -0.03%, respectively (P < .001). Patients between the ages of 70 and 74 years represented most of the patients undergoing a primary PIPA, whereas patients between 65 and 69 years most commonly underwent a revision procedure. Regionally, primary and revision PIPA were most commonly performed in the South. Conclusion: The data demonstrate an increased use of primary PIPA utilization for patients with OA, whereas revision PIPA decreased. The increased use indicates the increasing demand for PIPA in the United States.

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.

The Epidemiology and Trends of Primary Total Ankle Arthroplasty and Revision Procedure in Korea between 2007 and 2017

BACKGROUND

The aim of this study was to investigate the surgical trends of primary total ankle arthroplasty (TAA) and revision procedure in Korea from 2007 to 2017 using national population-based data.

METHODS

We reviewed the National Health Insurance data of Korea from 2007 to 2017. The data included diagnosis codes, procedure codes, prescriptions, medical costs, and other demographic data. Trends of primary diagnosis for primary TAA were evaluated. Annual trends and incidences per 100,000 person-years of primary TAA and revision procedures as well as compound annual growth rate (CAGR) during the study period were analysed. Surgical trends according to patients' age, hospital grades, and insurance systems were also evaluated.

RESULTS

Primary diagnosis for primary TAA was mostly degenerative arthritis (6,501 cases; 90.5%). From 2007 to 2017, the total number of cases of primary TAA and revision procedures was 7,183 and 585, respectively. The number of cases in 2007 of primary TAA was 313; there were no cases of revision. The number of cases in 2017 of primary TAA were 986 and of revision were 108. The CAGR during this period was 28.6% for primary TAA and 44.6% for revision procedures. Incidences per 100,000 person-years in 2017 were 1.91 for primary TAA and 0.21 for revision procedures. The average cost paid by patients themselves was USD 813 (19%) and by the National Health Insurance Service was USD 3,480 (81%).

CONCLUSION

The incidence of primary TAA and revision procedures steadily increases in Korea during the 11-year study period.

Trends in cervical disc arthroplasty and revisions in the Medicare database

Background

Due to increased postoperative complications with anterior cervical discectomy and fusion (ACDF), there has been an increasing interest in the use of cervical disc arthroplasty (CDA). Advancements in prosthetic designs and techniques have improved patient reported outcome measurements and minimized revision rates. There is a paucity in the literature regarding recent trends in CDA utilization and revision rates. The purpose of this study was to determine annual primary and revision CDA trends with the use of an administrative database.

Methods

A retrospective review from 2005-2014 was performed using the Medicare Standard Analytical Files from the PearlDiver supercomputer (PearlDiver Technologies, Fort Wayne, IN, USA). Patients who underwent primary CDA were queried using International Classification of Disease, ninth revision (ICD-9) and current procedural terminology (CPT) code 84.62 and 22856, respectively. Revision CDAs were queried using ICD-9 procedure code 84.66. Primary outcomes of this study included annual primary procedures, annual revision incidence (RI), and additional demographic data such as age, gender, geographic location, Charlson-Comorbidity Index (CCI); in addition to length of stay (LOS), cost, and reimbursement.

Results

The query returned 2,016 and 517 primary CDA and revision CDA procedures were performed in the Medicare database, respectively. The data showed that the CAGR of primary and revision CDA procedures to be 20.54% and 5.84% (P<0.001), respectively. RI and RB demonstrated a CAGR of -12.22% and -9.61%, respectively. Patients younger than the age of 65 represented the majority of the patients undergoing this procedure. Demographically, primary and revision CDAs were found highest in the South.

Conclusions

The data demonstrates a high rate of annual growth in CDA utilization (20.54%) and revision CDA (5.84%), indicating there is an increase demand for CDA in the United States. Compared to ACDF, patients who undergo CDA have improved patient reported outcome measurements and lower rates of postoperative complications.