Effects of Total Ankle Arthroplasty Training Course on Physician Practice Patterns and Complication Rates

Background. The purpose of this retrospective survey study was to determine the short-term effects of the AAOS/AOFAS total ankle arthroplasty (TAA) training course on participant practice patterns, implant preferences, and complication rates. Methods. An anonymous digital survey was administered via email to all 2012 and 2013 participants. Data regarding industry courses attended, implant system preferences, surgical indications, case volume, patient age, complication rates, and overall perceptions of TAA in the three months before and after the course were collected and analyzed. Results. Of the 87 participants contacted, 43 (49%) completed the entire survey. STAR (Small Bone Innovations, Inc., Morrisville, PA) was the most preferred implant before the course with 15 individuals listing it as top preference. A large percentage of participants (67%) changed implant preferences after the course. Of the 29 participants who changed preferences, 48% switched to INBONE II (Wright Medical, Arlington, TN) and 24% to STAR. Average number of TAAs performed in the 3 months before the course was 1.3 and increased significantly in the following 3 months to 2.1. Total number of reported intraoperative complications decreased from 12 before the course to 6 after, the most common being malleolar fractures. Overall, 84% of participants indicated that the course positively changed their use and perceptions of TAA and current implant systems. Conclusion. The main finding of this study was that the AAOS/AOFAS TAA training course changed implant system preferences, surgical indications, number of cases performed, and complication rates among participants in the short-term.

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Early Outcomes and Complications Following Initiation of a Total Ankle Arthroplasty Program

Foot & Ankle Orthopaedics ◽

10.1177/2473011420985780 ◽

2021 ◽

Vol 6 (1) ◽

pp. 247301142098578

Author(s):

Gregory Lundeen ◽

Kaitlin C. Neary ◽

Cody Kaiser ◽

Lyle Jackson

Keyword(s):

Intraoperative Complications ◽

Case Series ◽

Total Ankle Arthroplasty ◽

Radiographic Evaluation ◽

Wound Complications ◽

Consecutive Series ◽

Complication Rates ◽

Ankle Arthroplasty ◽

Intermediate Outcomes

Background: Surgeons who lack experience with total ankle arthroplasty (TAA) may remain hesitant to introduce this procedure owing to previously published results of high complication rates during initial cases. The purpose of the present study was to report the development of a TAA program through intermediate outcomes and complications for an initial consecutive series of TAA patients of a single community-based foot and ankle fellowship–trained orthopedic surgeon with little TAA experience using a co-surgeon with similar training and TAA exposure. Methods: The initial 20 patients following third-generation TAA with a single surgeon were reviewed. Clinical outcomes were measured and radiographs were evaluated to determine postoperative implant and ankle position. Complications were also measured including intraoperative, early (<3 months), and intermediate postoperative complications. Results: With a minimum follow-up of 2 years and average follow-up of 51 months (range 24-70 months), the mean American Orthopaedic Ankle & Foot Society Ankle-Hindfoot score was 87.7 (59-100) and VAS was 1.0 (0-5.5). All patients were improved following TAA. Radiographic evaluation demonstrated no evidence of component malalignment or ankle joint incongruity. There were no intraoperative complications nor any wound complications. Three patients returned to the operating room for placement of medial malleolar screw placement, and 1 had asymptomatic tibial component subsidence. Conclusions: Orthopedic surgeons with a proper background and updated training may be able to perform TAA with good outcomes. A TAA program was developed to define minimum training criteria to perform this procedure in our community. Our complication rate is consistent with those reported in the literature for experienced TAA centers, which contrasts previous literature suggesting increased complication rates and worse outcomes when surgeons perform initial TAAs. Utilization of an orthopedic co-surgeon was felt to be instrumental in the success of the program. Level of Evidence: Level IV, retrospective case series.

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Can Specific Implant Designs Implicate Variations in Outcomes of Total Ankle Arthroplasty? A Systematic Review

Foot & Ankle Orthopaedics ◽

10.1177/2473011417s000435 ◽

2017 ◽

Vol 2 (3) ◽

pp. 2473011417S0004

Author(s):

Dahang Zhao ◽

Dichao Huang ◽

Chen Wang ◽

Xin Xin Ma

Keyword(s):

Case Reports ◽

Intraoperative Complications ◽

Total Ankle Arthroplasty ◽

Implant Design ◽

Complication Rates ◽

Radiographic Findings ◽

Ankle Arthroplasty ◽

Surgeon Experience ◽

Comprehensive Search ◽

Reoperation Rates

Category: Ankle Arthritis Introduction/Purpose: Some complications of total ankle arthroplasty could not be reduced by improvement of surgeon experience. The purposes of the study were to determine whether there were variations in term of (1) intraoperative complications, (2) postoperative complication, (3) reoperation, revision and failure, and (4) postoperative radiographic findings among different studies. Methods: A comprehensive search was conducted. There were 953 for initial review. Initially, 136 irrelevant records, 174 review articles, 46 case reports and 1 retracted paper were excluded. Of the remaining 596 papers, 23 ultimately met our inclusion for final review. Results: Intraoperative fractures rates were higher studies of BP-type. Most of the pain or stiffness, malalignments, impingements, cysts were occurred in studies of STAR, HINTEGRA, Agility and Salto. Polyethylene insert fractures were occurred in most studies of STAR. Ten reported postoperative osseous fractures which all resulted from patients used STAR and BP-type. Reoperation rates were higher in studies of STAR, BP-type, Agility and Salto. Arthrodesis rates were lower from HINTEGRA. Arthrodesis rates from STAR, BP-type and Salto were higher than their revision rates. Periprosthetic lucency rates were lower from studies of HINTEGRA. The lucency rates of tibia were higher than talus. Cyst could be more easily observed from studies of STAR, Agility and Salto. All the osteoarthritis were reported in studies of STAR, BP-type and Agility. Conclusion: Currently the complication rates of TAA significantly decrease with modern implants, surgeons experience and patients selection. Some design-specific features of different prostheses were found in our study which could implicate variations in the complications and radiographic findings. We believed that these result could further improve the implant design.

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Effect of Travel Time and Distance on Outcomes in Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00154 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0015

Author(s):

Kristin C. Caolo ◽

Scott J. Ellis ◽

Jonathan T. Deland ◽

Constantine A. Demetracopoulos

Keyword(s):

Travel Time ◽

Complication Rate ◽

High Volume ◽

Total Ankle Arthroplasty ◽

Complication Rates ◽

Linear Regression Models ◽

Ankle Arthroplasty ◽

Significant Difference ◽

Drive Time

Category: Ankle; Ankle Arthritis Introduction/Purpose: Surgeons who perform a higher volume of total ankle arthroplasty (TAA) are known to have decreased complication rates; evidence shows that low volume centers performing TAA have decreased survivorship when compared with high volume centers. Understanding differences in outcomes for patients traveling different distances for their TAA is important for future patients deciding where to travel for their surgery. No study has previously examined differences in outcomes of patients traveling different distances to a high volume center for their TAA. This study compares preoperative and postoperative PROMIS scores for patients undergoing total ankle arthroplasty who traveled less than and more than 50 miles for their TAA. We hypothesized that there would be no difference in outcome scores based on distance traveled or estimated drive time. Methods: This study is a single center retrospective review of 162 patients undergoing primary total ankle arthroplasty between January 2016 and December 2018. We collected the primary address as listed in the patient’s medical record and used the directions feature on Google Maps to estimate driving mileage and estimated driving time from the patient’s address to the hospital. To analyze the distance patients traveled, patients were divided into two groups: <50 miles traveled (n=91) and >50 miles traveled (n=71). To analyze the estimated drive time, patients were divided into two groups: <90 minutes (n=77), >90 minutes (n=85). We collected preoperative and most recent postoperative PROMIS scores for all patients. Differences in most recent post-operative PROMIS scores between distance groups and travel time groups were assessed using multivariable linear regression models, adjusting for the pre-operative score and follow-up time. Results: We found no significant difference in post-operative PROMIS scores between the two groups when analyzed for distance traveled or for estimated travel time after adjustment for pre-operative PROMIS score and follow-up time (Table 1). The average follow-up for all 162 patients was 1.49 years. Power analysis showed that with a sample size of 110 (55 in each group), we had 81% power to detect an effect size of 4. Patients saw an increase in their Physical Function scores and a decrease in their Pain Interference and Pain Intensity scores with postoperative scores better than population means (Table 1). Overall complication rate for the <50 miles group was 17.6%, 7.7% required surgery. The >50 miles group had an overall complication rate of 24.0%, 9.9% required surgery. Conclusion: Patients traveling further distances to a high volume orthopedic specialty hospital for their total ankle arthroplasty do not have different clinical outcomes than patients traveling shorter distances. This is particularly important for patients deciding where to have their total ankle arthroplasty surgery. Patients who travel further have the opportunity to be treated at a local academic center; however our results show that outcomes do not change when traveling further for total ankle arthroplasty. [Table: see text]

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What! Another Short-Term Follow-up Paper on Total Ankle Arthroplasty?

The Journal of Bone and Joint Surgery (American) ◽

10.2106/jbjs.19.00700 ◽

2019 ◽

Vol 101 (16) ◽

pp. e84 ◽

Cited By ~ 1

Author(s):

Ronald W. Smith

Keyword(s):

Total Ankle Arthroplasty ◽

Short Term ◽

Ankle Arthroplasty

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Total ankle arthroplasty: what are the risks?

The Bone & Joint Journal ◽

10.1302/0301-620x.100b10.bjj-2018-0180.r1 ◽

2018 ◽

Vol 100-B (10) ◽

pp. 1352-1358 ◽

Cited By ~ 10

Author(s):

T. M. Clough ◽

F. Alvi ◽

H. Majeed

Keyword(s):

Informed Consent ◽

Literature Review ◽

Deep Infection ◽

Total Ankle Arthroplasty ◽

Complication Rates ◽

Superficial Infection ◽

Ankle Arthroplasty ◽

Wound Healing Problems ◽

Initial Hospital ◽

Ankle Function

Aims Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. Patients and Methods A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants. Results There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature. Conclusion Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent. Cite this article: Bone Joint J 2018;100-B:1352–8.

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Treatment Outcomes of Total Ankle Arthroplasty Using an Artificial Talus

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00219 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0021

Author(s):

Takaaki Hirano ◽

Yui Akiyama ◽

Tomoko Karube ◽

Naoki Haraguchi ◽

Hisateru Niki ◽

...

Keyword(s):

Treatment Outcomes ◽

Japanese Society ◽

Japanese Orthopaedic Association ◽

Total Ankle Arthroplasty ◽

Short Term ◽

Short Term Treatment ◽

Ankle Arthroplasty ◽

Patient Reported ◽

The Mean

Category: Ankle Arthritis Introduction/Purpose: Problems associated with mid- to long-term total ankle arthroplasty (TAA) include loosening and sinking of the talus implant. These problems arise due to a lack of stability compared with artificial joints such as knees and hips. In Japan, aluminum ceramic talus implants have been developed and are reported to result in good treatment outcomes. Here we investigated and report the treatment outcomes for combined TAA (cTAA), in which TAA is combined with a talus implant during the initial procedure. Methods: We assessed 15 cases involving 16 feet that underwent cTAA for which follow-up was available for at least 6 months. These cases comprised five feet with stage IIIb osteoarthritis and nine feet with stage IV osteoarthritis according to the Takakura classification as well as two feet with talus necrosis. The mean patient age was 73.5 years, and the mean follow-up period was 9.1 months. The talus implant was completely customized for all cases, and TNK Ankle (Kyocera, Japan) tibial components were used. Assessments were performed before and after surgery using the Japanese Society for Surgery of the Foot scale (JSSF scale) for physician-led objective evaluation and the Japanese Orthopaedic Association/Japanese Society for Surgery of the Foot and Self- Administered Foot Evaluation Questionnaire (SAFE-Q) subscales for patient-reported subjective evaluation. The validity and reliability of the JSSF scale and SAFE-Q have been verified by metering psychological verification. Scores were compared using paired t-tests. Results: The mean JSSF score improved significantly from 46.7 points preoperatively to 85.3 points postoperatively. For the SAFE-Q, pain and pain-related scores improved significantly from 40.5 points preoperatively to 75.8 points postoperatively (p < 0.001), physical function and daily lifestyle status improved significantly from 41.1 points preoperatively to 72.9 points postoperatively (p < 0.001), social lifestyle function improved significantly from 37.8 points preoperatively to 76.4 points postoperatively (p < 0.001), and overall sense of health improved significantly from 51.7 preoperatively to 80.7 postoperatively (p < 0.001). Shoe-related results improved from 50.0 points preoperatively to 69.4 points postoperatively (p = 0.038). Only one postoperative complication was noted, which was a case of deep wound infection. Conclusion: Short-term outcomes for cTAA were mostly good in our study population. The findings suggest that talus implants could be used as a treatment option for cases involving severe deformities, crushed talus injuries, and bone defects in which the use of TAA had previously been difficult, which can be handled with cTAA. These findings reveal new possibilities for expanded indications going forward. However, as these were short-term treatment outcomes, further follow-up is required in future studies.

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A Comparative Analysis of Short Term Postoperative Complications in Outpatient vs. Inpatient Total Ankle Arthroplasty

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00426 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0042 ◽

Cited By ~ 1

Author(s):

Ashish Shah ◽

Henry DeBell ◽

Chandler Tedder ◽

Zachariah Pinter ◽

Sameer Naranje ◽

...

Keyword(s):

Pulmonary Embolism ◽

Renal Failure ◽

Hospital Stay ◽

Operating Room ◽

Ankle Arthrodesis ◽

Total Ankle Arthroplasty ◽

Inpatient Setting ◽

Complication Rates ◽

Ankle Arthroplasty ◽

Significant Difference

Category: Ankle Introduction/Purpose: Ankle arthritis is a potentially debilitating disease with approximately 50,000 cases diagnosed annually. Once conservative management fails, surgical options for these patients include total ankle arthroplasty (TAA) and ankle arthrodesis. Younger, more active patients may prefer TAA as it may allow better ankle mobility compared to ankle arthrodesis. TAA has historically been performed in the inpatient setting with a one- to two-night postoperative hospital stay. Outpatient surgeries are gaining popularity due to their cost effectiveness, decreased length of hospital stay, and convenience. Therefore, it is important to evaluate the safety of specific procedures in the outpatient setting compared to the inpatient setting. This study evaluates the complication rates in inpatient vs. outpatient TAA. Methods: Our team conducted a retrospective analysis of data from 591 patients receiving inpatient and outpatient TAA from the NSQIP database. This database contains de-identified patient data and allows retrospective analyses to be performed based on data they have extracted from over 400 hospitals. Demographic information was recorded including age, sex, weight, height, and race. Thirty-day postoperative complication rates were compared between 66 outpatients and 535 inpatients. Frequencies of the following complications were analyzed: wound complications, pneumonia, hematologic complications (pulmonary embolism and deep vein thrombosis), renal failure, stroke, and return to the operating room within 30 days. The inpatient and outpatient groups were compared using chi-squared tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Results: 591 total patients were identified that underwent TAA. 66 patients (11.1%) were treated as outpatients and 525 (88.8%) as inpatients. Inpatient TAA had a significantly higher mean operation time (161 min vs 148 min) and a significant difference in length of total hospital stay (2.3 days vs 1.1 days). Inpatients had higher rates of superficial incisional surgical site infection (SSI) (0.57% vs 0%), deep SSI (0.19 % vs 0%), organ/space SSI (0.19% vs 0%), pneumonia (0.38% vs 0%), and return to the operating room (0.76% to 0%). However, no significant differences were found in complication rates between inpatient and outpatient groups. There were no occurrences of acute renal failure, wound disruption, pulmonary embolism, stroke, or DVT/thrombophlebitis for inpatients or outpatients. Conclusion: We found no significant difference between inpatient vs. outpatient TAA. Incidental differences we found were that inpatients were significantly more likely to be older in age, diagnosed with diabetes, and inpatients had longer operative times. Our results suggest that inpatients are more likely, but not significantly, to have a higher occurrence of complications and return to the OR. Therefore, this study suggests that outpatient TAA is safe and may be a superior option for the correct patient population. Further investigation is warranted to verify these conclusions.

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A Review of Perioperative Complications of Outpatient Total Ankle Arthroplasty

Foot & Ankle International ◽

10.1177/1071100717738748 ◽

2017 ◽

Vol 39 (2) ◽

pp. 143-148 ◽

Cited By ~ 13

Author(s):

Todd R. Borenstein ◽

Kapil Anand ◽

Quanlin Li ◽

Timothy P. Charlton ◽

David B. Thordarson

Keyword(s):

Wound Infection ◽

Pain Control ◽

Perioperative Complications ◽

Case Series ◽

Arterial Occlusion ◽

Total Ankle Arthroplasty ◽

Complication Rates ◽

Ankle Arthroplasty ◽

Wound Breakdown

Background: Total ankle arthroplasty (TAA) is commonly pursued for patients with painful arthritis. Outpatient TAA are increasingly common and have been shown to decrease costs compared to inpatient surgery. However, there are very few studies examining the safety of outpatient TAA. In this study, we retrospectively reviewed 65 consecutive patients who received outpatient TAA to identify complication rates. Methods: The medical records of 65 consecutive outpatient TAA from October 2012 to May 2016 with a minimum 6-month follow-up were reviewed. All patients received popliteal and saphenous blocks prior to surgery and were managed with oral pain medication postoperatively. All received a STAR total ankle. Demographics, comorbidities, American Society of Anesthesiologists (ASA) class, and perioperative complications including wound breakdown, infection, revision, and nonrevision surgeries were observed. Mean follow-up was 16.6 ± 9.1 months (range, 6-42 months). Results: There were no readmissions for pain control and 1 patient had a wound infection. The overall complication rate was 15.4%. One ankle (1.5%) had a wound breakdown requiring debridement and flap coverage. This patient thrombosed a popliteal artery stent 1 month postop. The 1 ankle (1.5%) with a wound infection occurred in a patient with diabetes, obesity, hypertension, and rheumatoid arthritis. Conclusion: This study demonstrates the safety of outpatient TAA. The combination of regional anesthesia and oral narcotics provided a satisfactory experience with no readmissions for pain control and 1 wound infection. The 1 wound breakdown complication (1.5%) was attributed to arterial occlusion and not outpatient management. Level of Evidence: Level IV, retrospective case series.

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