Primary vs. Revision Ankle Arthrodesis: Comparison of Fusion and Complication Rates

Background Surgical management of end-stage ankle arthritis consists of either ankle arthrodesis (AA) or total ankle replacement (TAR). The purpose of this study was to evaluate utilization trends in TAR and AA and compare cost and complications. Methods Medicare patients with the diagnosis of ankle arthritis were reviewed. Patients undergoing surgical intervention were split into AA and TAR groups, which were evaluated for trends as well as postoperative complications, revision rates, and procedure cost. Results A total of 673 789 patients were identified with ankle arthritis. A total of 19 120 patients underwent AA and 9059 underwent TAR. While rates of AA remained relatively constant, even decreasing, with 2080 performed in 2005 and 1823 performed in 2014, TAR rates nearly quadrupled. Average cost associated with TAR was $12559.12 compared with $6962.99 for AA ( P < .001). Overall complication rates were 24.9% in the AA group with a 16.5% revision rate compared with 15.1% and 11.0%, respectively, in the TAR group ( P < .001). Patients younger than 65 years had both higher complication and revision rates. Discussion TAR has become an increasingly popular option for the management of end-stage ankle arthritis. In our study, TAR demonstrated both lower revision and complication rates than AA. However, TAR represents a more expensive treatment option. Levels of Evidence: Level III: Retrospective comparative study

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Primary open vs. arthroscopic ankle arthrodesis: Comparison of fusion and complication rates

Foot and Ankle Surgery ◽

10.1016/j.fas.2017.07.228 ◽

2017 ◽

Vol 23 ◽

pp. 47-48

Author(s):

A. Barg ◽

C. Saltzman

Keyword(s):

Ankle Arthrodesis ◽

Complication Rates

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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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Primary open vs. arthroscopic ankle arthrodesis: Comparison of fusion and complication rates

Foot and Ankle Surgery ◽

10.1016/j.fas.2016.05.262 ◽

2016 ◽

Vol 22 (2) ◽

pp. 100

Author(s):

A. Barg ◽

M. Lyman ◽

C. Morris ◽

C. Saltzman

Keyword(s):

Ankle Arthrodesis ◽

Complication Rates

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Primary vs. revision ankle arthrodesis: Comparison of fusion and complication rates

Foot and Ankle Surgery ◽

10.1016/j.fas.2016.05.263 ◽

2016 ◽

Vol 22 (2) ◽

pp. 100-101

Author(s):

A. Barg ◽

M. Lyman ◽

C. Morris ◽

C. Saltzman

Keyword(s):

Ankle Arthrodesis ◽

Complication Rates

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Does Concurrent Distal Tibiofibular Joint Arthrodesis Affect the Nonunion and Complication Rates of Tibiotalar Arthrodesis?

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00367 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0036

Author(s):

Julie Neumann ◽

Maxwell Weinberg ◽

Chong Zhang ◽

Charles Saltzman ◽

Alexej Barg

Keyword(s):

Wound Complication ◽

Ankle Arthrodesis ◽

Primary Outcome Measure ◽

Secondary Outcome ◽

Wound Complications ◽

Complication Rates ◽

Vein Thrombosis ◽

Significant Difference ◽

Tibiotalar Arthrodesis ◽

End Stage

Category: Ankle Introduction/Purpose: Tibiotalar arthrodesis is generally a successful treatment option for patients with end stage ankle arthritis. However, there is a 9% risk of nonunion in patients undergoing primary tibiotalar arthrodesis. To date, it is unclear whether concurrent distal tibio-fibular joint arthrodesis affects this nonunion rate as there have been no studies directly comparing patients with and without arthrodesis of the distal tibio-fibular joint. The purpose of this clinical study is to compare the rate of nonunion in patients with a distal tibio-fibular fusion to those without a distal tibio-fibular fusion in the setting of a primary, open ankle arthrodesis. The hypothesis of this study was that the addition of a distal tibio-fibular fusion would decrease the nonunion rate in patients undergoing open ankle arthrodesis. Methods: This is a retrospective review of 521 consecutive patients from October 2002 to April 2016. 366 ankles from 354 unique patients met inclusion criteria. All patients underwent primary, open tibiotalar arthrodesis. 250 patients underwent open tibiotalar arthrodesis with a distal tibio-fibular fusion and 116 patients underwent open tibiotalar arthrodesis without a distal tibio-fibular fusion. Age, gender, body mass index, smoking, and preoperative radiographic deformity were controlled. The primary outcome measure was nonunion rate of tibiotalar arthrodesis. Secondary outcome measures were time to union, rate of wound complications, and rate of development of post-operative deep vein thrombosis (DVT)/Pulmonary embolism (PE). Results: Average age of the patients was 56.2 +/- 14.2 years. Mean follow-up time was 33.8 months. Unions were assessed on routine post-operative radiographs and by clinical examination. If there was a concern for nonunion, computerized tomography scan was utilized for further assessment. Nonunion rate of patients who had the distal tibio-fibular joint included was 19/250 (8%) and nonunion rate of those who did not have the distal tibio-fibular joint fused was 14/116 (12%) (p=0.16). There was no significant difference between those who had the distal tibio-fibular joint included versus who did not in wound complication rate (27% vs 31%, p=0.40), time to union (4.9 weeks versus 5 weeks, p =0.54), and DVT/PE rate (5% vs 3%, p=0.41), respectively [Table 1]. There were no major complications. Conclusion: To our knowledge, this is the first study directly comparing nonunion rates and complication rates in patients who underwent primary, open ankle arthrodesis with and without distal tibio-fibular joint arthrodesis. In this study, inclusion of the distal tibio-fibular joint in tibiotalar arthrodesis does not affect nonunion rate in patients undergoing primary, open ankle arthrodesis. Additionally, inclusion of the distal tibio-fibular joint does not affect rate of wound complication, time to union, and DVT/PE rate.

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A Comparison of Cost and Complications of Total Ankle Arthroplasty and Ankle Arthrodesis for the Management of Ankle Arthritis

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00496 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0049

Author(s):

William Tucker ◽

Bandon Barnds ◽

Scott Mullen ◽

Paul Schroeppel ◽

Bryan Vopat

Keyword(s):

Large Scale ◽

Statistical Significance ◽

Disease Process ◽

Ankle Arthrodesis ◽

Reoperation Rate ◽

Complication Rates ◽

Ankle Arthritis ◽

Patient Health ◽

Initial Procedure ◽

Reoperation Rates

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis is a relatively common ailment that affects many people. The method of surgical management of this disease process is usually an ankle arthrodesis (AA) or a total ankle replacement (TAR). Traditionally, AA was viewed as the “gold standard”, however TAR has grown in popularity. Numerous studies have evaluated the risks and benefits of each of these treatments including satisfaction, biomechanics, and cost. The purpose of this study was to compare the cost and rate of complications for patients who underwent either an AA or TAR using a large database. Methods: Using the PearlDiver Technologies, Inc. database, Medicare patients who were diagnosed with ankle arthritis based on ICD-9 codes from 2005 to 2014 were analyzed. Patients were identified who underwent either AA or TAR utilizing ICD-9 procedure and CPT codes. These patient groups were evaluated for postoperative complications and reoperation rates. Subjects and associated costs were followed after the initial procedure. A cost analysis based on diagnosis and procedural codes was then performed on the separate groups, using a t-test to determine statistical significance. Data was analyzed with regards to standard demographic information as well as a metric of overall patient health status, the Charlson Comorbidity Index (CCI). Results: During the study period, 673,789 patients were identified with the diagnosis of ankle arthritis. Of those, 19,120(2.8%) underwent AA and 9,059 (1.3%) underwent TAR. While the yearly rate of AA performed remained stable, TAR was performed at increasing rates. The overall complication rate in the AA group was 24.9% with a 16.5% revision rate compared to 15.1% and 11.2% respectively in the TAR group (P<0.001). Also, the AA group had a higher total reoperation rate. The CCI was found to be significantly lower in the TAR group at 4.5 versus 4.7 in AA patients (P<0.001). Patients younger than 65 years old had both higher complication and reoperation rate. The average one-year cost associated with TAR was $12,566.15 and with AA was $6,967.32 (P<0.001). Conclusion: While TAR was found to be a more expensive treatment option than AA in this large-scale database study, patients in this group had significantly lower complication rates. The reoperation rates were also lower in the TAR group. The CCI was noted to be slightly lower in the arthroplasty group, meaning these patients may have been healthier, representing a selection bias. Also, the patients that had complications were found to have a higher CCI on average. When choosing surgical intervention for end-stage ankle arthritis, patients should be counseled on cost differences and potential complications for TAR and AA.

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Contemporary Comparison of Short-Term Outcomes after Total Ankle Replacement and Ankle Arthrodesis

Foot & Ankle Orthopaedics ◽

10.1177/2473011419s00089 ◽

2019 ◽

Vol 4 (4) ◽

pp. 2473011419S0008

Author(s):

Junho Ahn ◽

Kshitij Manchanda ◽

Stephen Wallace ◽

Dane K. Wukich ◽

George T. Liu ◽

...

Keyword(s):

Multivariate Regression ◽

Ankle Arthrodesis ◽

Patient Data ◽

Adverse Outcomes ◽

Total Ankle Replacement ◽

Complication Rates ◽

Short Term ◽

Acs Nsqip ◽

Ankle Replacement ◽

Acs Nsqip Database

Category: Ankle, Ankle Arthritis Introduction/Purpose: During the last twenty years, studies comparing total ankle replacement (TAR) and ankle arthrodesis (AA) appear to demonstrate lower complication rates with TAR than with AA. However, advances in implant technology and surgical techniques have dramatically reduced complication rates. As a result, studies comparing TAR and AA require more patients to detect differences in rare events. Despite this, few epidemiologic studies have been performed examining short-term outcomes after TAR and AA using a contemporary patient population. The purpose of the current study was to compare perioperative outcomes after TAR and AA using patient data from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database between 2012 and 2017. Methods: We reviewed patient data from ACS-NSQIP database collected between 2012 and 2017 using Current Procedural Terminology (CPT) codes 27700 (TAR), 27702 (TAR), 29899 (AA) and 27870 (AA). Patients were then excluded if they were treated for fractures, infections, non-foot or ankle-related conditions or had revision procedures. Patients were also excluded if they were older than 90 years as ACS-NSQIP does not report age above 90 years. The study population included those treated in inpatient and outpatient settings. The main outcomes of interest were readmission and reoperation related to initial surgery, surgical site complications and hospital length of stay (LOS). Predictors of adverse outcomes were evaluated through multivariate regression of patient demographics, comorbidities and treatment characteristics. Results: Out of 1214 patients included in the study, 187 (15.4%) patients were treated with AA, and 1027 (84.6%) underwent TAR. Patients with AA were younger, had higher body-mass index, higher white blood cell count, more often had diabetes mellitus (DM) treated with insulin, received more dialysis treatment, had higher anesthesia risk classification and were treated in the outpatient setting more often than patients with TAR. Among outcomes, AA patients had longer hospital LOS, more deep surgical site infections and more reoperations than TAR patients. Post-operative readmissions were not significant but were higher in AA patients (2.7% vs. 0.9%, p=0.101). Combining these adverse outcomes, multivariate regression revealed that higher anesthesia risk category (p=0.0007), DM (p=0.029) and AA (p=0.049) had positive correlations with adverse outcomes. Conclusion: Ankle arthrodesis appears to be independently associated with perioperative complications compared to TAR, consistent with previous reports. Although complications were rare, patients with DM and higher anesthesia risk seem to be important factors to consider. Interestingly, patients with DM had fewer adverse outcomes with TAR than AA (3.8% vs. 7.4%). The difference was even greater in DM patients treated with insulin (4.3% vs. 13.3%) although only 38 patients had DM controlled with insulin in the cohort. Further studies are needed to identify patient populations at risk of complications, specifically those with DM.

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