SLR - October 2023 - Novoshelski
Title: Complications Following Total Ankle Arthroplasty Versus Ankle Arthrodesis for Primary Ankle OsteoarthritisReference: Ross BJ, Savage-Elliott I, Wu VJ, Rodriguez RF. Complications following total ankle arthroplasty versus ankle arthrodesis for primary ankle osteoarthritis. Foot Ankle Spec. 2023. 16(1): 20–27.
Level of Evidence: Level 3
Scientific Literature Review
Reviewed by: Shaun Novoshelski, DPM
Residency Program: Temple University Hospital, Philadelphia, PA
Podiatric Relevance: Osteoarthritis is a common medical condition that affects approximately 10% of all patients over 60 years old. Of the 10% that are affected, approximately 12% of those will be symptomatic to the lower extremity. Historically speaking, ankle arthrodesis for end-stage ankle arthritis has been a gold standard. With the increase in ankle implant technologies, the utilization of these devices has increased approximately 57% between the years of 2004 and 2009. Understanding the outcomes and complications associated with treatment modalities for end-stage ankle arthritis will allow for appropriate procedure selection and improved patient outcomes.
Method: A retrospective cohort study was designed to compare post-operative complications for patients who received a Total Ankle Arthroplasty (TAR) or Ankle Arthrodesis (AA) between the years of 2010-2019. Only patients with a preoperative diagnosis of ankle osteoarthritis were included from the query. Exclusion criteria included posttraumatic arthritis, traumatic arthropathy, lateral/medial malleolar fractures, other traumatic etiologies, active ankle infection, calcaneal osteotomy, or Achilles tendon lengthening. A total of 1,720 patients were included in the study. Rates of major postoperative joint complications were queried from the database using ICD-9, ICD-10, and CPT codes for the 90-day, 1-year, and 2-year postoperative periods. Procedure-specific complications assessed included malunion or nonunion (AA), revision, local open reduction and internal fixation, and aseptic mechanical complications (prosthetic dislocation, loosening, or breakage, periprosthetic osteolysis, and wear of the articular bearing surface) for TAR. Additional complications also examined included prosthetic joint infection, subsequent osteotomy, adjacent fusions, and hardware removal. Complications that were not studied included superficial wound complications, non-joint complications, or delayed wound healing. Major comorbidities that were also collected were diabetes mellitus, hypertension, Rheumatoid arthritis, and Tobacco.
Results: Sixty-seven percent of patients included underwent AA. TAR patients accounted for 33% of the cohort. The proportion of patients with at least one joint complication was higher for the AA cohort at 90 days (19.3% vs. 12.6%), 1 year (25.6% vs. 15%), and 2 years (26.9% vs. 16.2%). The most common complications at 2 years following TAR were hardware removal, aseptic mechanical complications, and other fusions or osteotomies. For ankle arthrodesis, the most common complication at 2 years was hardware removal, or other osteotomy/fusion. Ankle arthrodesis demonstrated higher rates of osteotomies/fusions, periprosthetic fracture, and hardware removal at 90 days, 1 and 2 years. Infection rates at 2 years were comparable for both groups.
Conclusion: Patients who underwent ankle arthrodesis demonstrated higher rates of joint complications as compared to the patients who underwent total ankle arthroplasty. These complications included adjacent fusion and osteotomies, hardware removal, and periprosthetic fracture. Several limitations were noted in this paper. Even though patients with documented ankle fractures, inflammatory or infectious processes and post traumatic arthritis were excluded, diagnosis codes for soft tissue injuries that can progress to post traumatic osteoarthrosis were not included in the exclusion criteria. Also, the definition of primary ankle osteoarthritis included diagnosis codes from primary and secondary osteoarthritis; some patients that were included may not have hade true primary osteoarthritis.