Sex Differences in End-Stage Ankle Arthritis and Following Total Ankle Replacement or Ankle Arthrodesis.

BACKGROUND: We investigated the influence of sex on patient-reported outcomes preoperatively and following total ankle replacement and ankle arthrodesis. METHODS: Patients who had undergone total ankle replacement or ankle arthrodesis for the treatment of end-stage ankle arthritis and who had ≥2 years of follow-up were identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database. Standard surgical techniques and implantation methods were followed, and STAR, Hintegra, Mobility, and Agility prostheses were used. Data were collected on patient demographics, revisions, secondary procedures, complications, Ankle Osteoarthritis Scale (AOS) scores, Short Form-36 (SF-36) scores, and expectations and satisfaction. Statistical analyses included 3-way repeated-measures analysis of variance (ANOVA) and multiple linear regression models controlling for inflammatory arthritis, age, preoperative scores, and surgery type. RESULTS: The study included 872 patients: 629 who had undergone total ankle replacement (316 men, 313 women) and 243 who had undergone ankle arthrodesis (154 men, 89 women). The mean duration of follow-up (and standard deviation) was 4.9 ± 2.4 and 4.0 ± 1.9 years for the total ankle replacement and ankle arthrodesis groups, respectively. Men were older than women (p ≤ 0.001). In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS pain scores (i.e., more pain) than men preoperatively (p < 0.05). Pain was reduced significantly in both sexes postoperatively (p < 0.05), with no significant difference between sexes. In both the total ankle replacement and ankle arthrodesis groups, women had higher AOS disability scores (i.e., more disability) and lower SF-36 Physical Component Summary (PCS) scores (i.e., worse function) than men both preoperatively and postoperatively (p < 0.001). Postoperatively, AOS disability and SF-36 PCS scores improved significantly from baseline in both sexes (p < 0.001). After controlling for covariates, sex was not a significant predictor of postoperative SF-36 MCS (Mental Component Summary), AOS pain, or AOS disability scores (p > 0.05) but explained 0.5% of variance in SF-36 PCS scores (p = 0.03). Sex did not significantly influence preoperative expectations or postoperative satisfaction. When patients with inflammatory arthritis were excluded, preoperative and postoperative outcome measures, expectations, and satisfaction were similar. CONCLUSIONS: Men and women with end-stage ankle arthritis benefited from total ankle replacement and ankle arthrodesis with similar magnitudes of improvement. Small differences in pain and function between men and women undergoing total ankle replacement and ankle arthrodesis mostly disappeared when controlling for potential confounding variables. Both total ankle replacement and ankle arthrodesis remain good options for men and women with end-stage ankle arthritis. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Total Ankle Replacement, Arthroscopic Ankle Arthrodesis, and Open Ankle Arthrodesis for Isolated Non-Deformed End-Stage Ankle Arthritis.

BACKGROUND: End-stage ankle arthritis is a disabling condition that has a similar effect on morbidity, pain, and loss of function to hip arthritis. We compared clinical outcomes of total ankle replacement (TAR) involving the HINTEGRA prosthesis (Integra LifeSciences), arthroscopic ankle arthrodesis (AAA), and open ankle arthrodesis (OAA) in patients with isolated, non-deformed end-stage ankle arthritis. METHODS: Patients ≥18 years old who underwent TAR, AAA, or OAA from 2002 to 2012 with a minimum follow-up of 2 years were retrospectively identified from the Canadian Orthopaedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstruction Database. All patients had symptomatic COFAS Type-1 end-stage ankle arthritis without intra-articular or extra-articular deformity or surrounding joint arthritis. Clinical outcomes included the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36). Revision was defined as removal of 1 or both metal ankle prosthesis components for TAR and as reoperation for malposition, malunion, or nonunion for AAA and OAA. RESULTS: Analysis included 238 ankles (88 TAR, 50 AAA, and 100 OAA) in 229 patients with a mean follow-up of 43.3 ± 18.5 months. The TAR group had more female patients (55%; p = 0.0318) and a higher mean age (p = 0.0005). Preoperative AOS pain, disability, and total scores were similar for all groups. SF-36 physical and mental component summary scores were similar across groups, both preoperatively and postoperatively. Improvement in AOS total score was significantly larger for TAR (34.4 ± 22.6) and AAA (38.3 ± 23.6) compared with OAA (25.8 ± 25.5; p = 0.005). Improvement in AOS disability score was also significantly larger for TAR (36.7 ± 24.3) and AAA (40.5 ± 26.4) compared with OAA (26.0 ± 26.2; p = 0.0013). However, the greater improvements did not meet the minimal clinically important difference. The TAR group underwent more reoperations than AAA and OAA groups (p < 0.0001). Revision rates were similar for all 3 groups (p = 0.262). CONCLUSIONS: AAA and OAA resulted in comparable clinical outcomes to TAR in patients with non-deformed, COFAS Type-1 end-stage ankle arthritis. The rate of component revision in patients who underwent TAR was similar to the rate of revision for patients who underwent AAA or OAA; however, TAR patients underwent a greater number of additional procedures. Overall, AAA and TAR involving the HINTEGRA prosthesis were not significantly different surgical options in terms of short-term outcomes; patients should be counseled regarding higher reoperation rates for TAR. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Coding System for Reoperations Following Total Ankle Replacement and Ankle Arthrodesis.

BACKGROUND: Repeated surgery can be a measure of failure of the primary surgery. Future reoperations might be avoided if the cause is recognized and procedures or devices modified accordingly. Reoperations result in costs to both patient and the health care system. This paper proposes a new classification system for reoperations in end-stage ankle arthritis, and analyzes reoperation rates for ankle joint replacement and arthrodesis surgeries from a multicenter database. METHODS: A total of 213 ankle arthrodeses and 474 total ankle replacements were prospectively followed from 2002 to 2010. Reoperations were identified as part of the prospective cohort study. Operating reports were reviewed, and each reoperation was coded. To verify inter- and intraobserver reliability of this new coding system, 6 surgeons experienced in foot and ankle surgery were asked to assign a specific code to 62 blinded reoperations, on 2 separate occasions. Reliability was determined using intraclass correlation coefficients (ICCs) and proportions of agreement. RESULTS: Of a total of 687 procedures, 74.8% (514/687) required no reoperation (Code 1). By surgery type, 14.1% (30/213) of ankle arthrodesis procedures and 30.2% (143/474) of ankle replacement procedures required reoperation. The rate for reoperations surrounding the ankle joint (ie, Codes 2 and 3) was 9.9% (21/213) for ankle arthrodesis versus 5.9% for ankle replacement (28/474). Reoperation rates within the ankle joint (ie, Codes 4 to 10) were 4.7% (10/213) for ankle arthrodesis and 26.1% (124/474) for ankle replacement. Overall, 0.9% (2/213) of arthrodesis procedures required reoperation outside the initial operative site (Code 3), versus 4.6% (22/474) for total ankle replacement. The rate of reoperation due to deep infection (Code 7) was 0.9% (2/213) for arthrodesis versus 2.3% (11/474) for ankle replacement. Interobserver reliability testing produced a mean ICC of 0.89 on the first read. The mean ICC for intraobserver reliability was 0.92. For interobserver, there was 87.9% agreement (804/915) on the first read, and 87.5% agreement (801/915) on the second. For the intra observer readings, 88.5% (324/366) were in agreement. CONCLUSIONS: The new coding system presented here was reliable and may provide a more standardized, clinically useful framework for assessing reoperation rates and resource utilization than prior complication- and diagnosis-based classification systems, such as modifications of the Clavien Dindo System. Analyzing reoperations at the primary site may enable a better understanding of reasons for failure, and may therefore improve the outcomes of surgery in the future. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort study based on prospectively collected data.

Patient expectation and satisfaction as measures of operative outcome in end-stage ankle arthritis: a prospective cohort study of total ankle replacement versus ankle fusion.

BACKGROUND: Current operative outcome scales are based on pain and function, such as the Ankle Osteoarthritis Scale (AOS). Outcomes based on patient expectation and satisfaction may be more useful. The purpose of this prospective cohort study was to evaluate associations between patient expectation, satisfaction, and outcome scores for ankle fusion and total ankle replacement (TAR). METHODS: In total, 654 ankles in 622 patients were analyzed at a mean of 61 months. Patient expectation and satisfaction with symptoms were quantified pre- and postoperatively using the Musculoskeletal Outcomes Data Evaluation and Management Scale questionnaires from the American Academy of Orthopaedic Surgeons, while function was quantified using the AOS. RESULTS: Patients undergoing ankle replacement had a higher preoperative expectation score (79; 95% confidence interval [CI], 77-81) compared with those undergoing ankle fusion (72; 95% CI, 68-75). Preoperative expectation scores correlated weakly with AOS scores (R (2) = 0.02) and with the "expectations met" score for ankle fusion (R (2) = 0.07) but not for ankle replacement (R (2) < 0.01). Satisfaction scores were similar for ankle fusion and ankle replacement at follow-up, but a greater number of ankle replacement patients showed improvement in satisfaction (84% vs 74%, P < .005). Higher satisfaction at final follow-up was associated with better expectations met and greater improvement in AOS outcome scores for both ankle fusion and ankle replacement. Expectations met and AOS scores at follow-up correlated for ankle fusion (R (2) = 0.38, P < .0001) and ankle replacement (R (2) = 0.31, P < .0001). CONCLUSIONS: Patients undergoing TAR had higher expectation scores prior to surgery than those undergoing ankle fusion. Expectations may be more likely to be met by ankle replacement compared with ankle fusion. Ankle replacement patients were more likely to report improved satisfaction scores after surgery. Preoperative expectation scores showed little correlation with preoperative AOS scores, indicating that expectation is independent of pain and function. However, postoperative expectations met and satisfaction scores were strongly associated with AOS scores at follow-up. Better preoperative patient education may change expectations and requires study. LEVEL OF EVIDENCE: Level II, prospective cohort study.

Outcome of total ankle arthroplasty in patients with rheumatoid arthritis and noninflammatory arthritis. A multicenter cohort study comparing clinical outcome and safety.

BACKGROUND: Patients with rheumatoid arthritis often have degeneration of the ankle and ipsilateral hindfoot joints. Patients with rheumatoid arthritis undergoing total ankle arthroplasty have a higher risk of wound breakdown and infection. We compared intermediate-term clinical outcomes after total ankle arthroplasty in patients with rheumatoid arthritis and patients with noninflammatory arthritis. METHODS: Fifty patients with rheumatoid arthritis were compared with fifty patients with noninflammatory arthritis (the control group), matched for age within ten years, prosthesis type, and follow-up time. All patients underwent total ankle arthroplasty. Revisions and major complications were noted. Outcome scores included the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) Health Survey. RESULTS: The groups were similar with respect to body mass index and length of follow-up (mean, 63.8 months for the rheumatoid arthritis group and 65.6 months for noninflammatory arthritis group); the rheumatoid arthritis group was younger (mean, 58.5 years compared with 61.2 years). The mean AOS pain scores were significantly different in the rheumatoid arthritis and noninflammatory arthritis groups preoperatively (p < 0.01), but were similar following total ankle arthroplasty (mean and standard deviation, 18.5 ± 17.8 for the rheumatoid arthritis group and 19.7 ± 16.5 for the noninflammatory arthritis group; p = 0.93). Both groups showed significant improvement (p < 0.05) with regard to the AOS scores for pain and disability and SF-36 physical component summary scores following surgery. Postoperatively, AOS disability and SF-36 physical component summary scores were better for patients with noninflammatory arthritis. There were seven revisions in the rheumatoid arthritis group and five in noninflammatory arthritis group. There was one major wound complication in the rheumatoid arthritis cohort and none in the control cohort. CONCLUSIONS: Patients with rheumatoid arthritis benefit from total ankle arthroplasty and have similar outcomes to patients with noninflammatory arthritis. The overall pain and disability were worse for patients with rheumatoid arthritis than for those with noninflammatory arthritis preoperatively, but this did not negatively influence their final outcomes. When properly treated, patients with rheumatoid arthritis achieve good results.

Intermediate-term results of total ankle replacement and ankle arthrodesis: a COFAS multicenter study.

BACKGROUND: Surgical treatments for end-stage ankle arthritis include total ankle replacement and ankle arthrodesis. Although arthrodesis is a reliable procedure, ankle replacement is often preferred by patients. This prospective study evaluated intermediate-term outcomes of ankle replacement and arthrodesis in a large cohort at multiple centers, with variability in ankle arthritis type, prosthesis type, surgeon, and surgical technique. We hypothesized that patient-reported clinical outcomes would be similar for both procedures. METHODS: Patients in the Canadian Orthopaedic Foot and Ankle Society (COFAS) Prospective Ankle Reconstruction Database were treated with total ankle replacement (involving Agility, STAR, Mobility, or HINTEGRA prostheses) or ankle arthrodesis by six subspecialty-trained orthopaedic surgeons at four centers between 2001 and 2007. Data collection included demographics, comorbidities, and the Ankle Osteoarthritis Scale (AOS) and Short Form-36 (SF-36) scores. The preoperative and latest follow-up scores for patients with at least four years of follow-up were analyzed. Sensitivity analyses excluded ankles that had undergone revision. A linear mixed-effects regression model compared scores between the groups, adjusting for age, sex, side, smoking status, body mass index, inflammatory arthritis diagnosis, baseline score, and surgeon. RESULTS: Of the 388 ankles (281 in the ankle replacement group and 107 in the arthrodesis group), 321 (83%; 232 ankle replacements and eighty-nine arthrodeses) were reviewed at a mean follow-up of 5.5 ± 1.2 years. Patients treated with arthrodesis were younger, more likely to be diabetic, less likely to have inflammatory arthritis, and more likely to be smokers. Seven (7%) of the arthrodeses and forty-eight (17%) of the ankle replacements underwent revision. The major complications rate was 7% for arthrodesis and 19% for ankle replacement. The AOS total, pain, and disability scores and SF-36 physical component summary score improved between the preoperative and final follow-up time points in both groups. The mean AOS total score improved from 53.4 points preoperatively to 33.6 points at the time of follow-up in the arthrodesis group and from 51.9 to 26.4 points in the ankle replacement group. Differences in AOS and SF-36 scores between the arthrodesis and ankle replacement groups at follow-up were minimal after adjustment for baseline characteristics and surgeon. CONCLUSIONS: Intermediate-term clinical outcomes of total ankle replacement and ankle arthrodesis were comparable in a diverse cohort in which treatment was tailored to patient presentation; rates of reoperation and major complications were higher after ankle replacement.