SLR - October 2022 - Sindhu Srinivas, DPM, MS
ReferenceParacha N, Idrizi A, Gordon AM, Lam AW, Abdelgawad AA, Razi AE. Utilization Trends of Total Ankle Arthroplasty and Ankle Fusion for Tibiotalar Osteoarthritis: A Nationwide Analysis of the United States Population. Foot Ankle Spec. 2022 Jul 17:19386400221110133. doi: 10.1177/19386400221110133. Epub ahead of print. PMID: 35848212.
Level of Evidence: Level of Evidence III
Reviewed By: Sindhu Srinivas, DPM, MS
Residency Program: Geisinger Community Medical Center- Scranton, PA
Podiatric Relevance:
End-state osteoarthritis (OA) often requires surgical intervention to regain function. Total ankle arthroplasty (TAA) and Ankle Fusion (AF) are known interventions for OA. Outcomes comparing TAA vs AF are sparse in literature. The aim of this study was to utilize a national administrative claims database comparing demographics between TAA and AF, determining if patients undergoing TAA had increased rates of utilization, in-hospital length of stay (LOS) and costs of care.
Methods:
A query was performed from January 1, 2005 to December 31, 2013 utilizing PearlDriver. PearlDriver is a registry-based platform housing Medicare and private payor information in two separate categories. The database was queried for patients who had osteoarthritis with their corresponding ICD-9 code. Additionally, patients undergoing TAA or AF were identified with corresponding ICD-9 and CPT codes. Primary endpoints were comparing demographics between patients who underwent TAA or AF utilizing Elixbauser comorbidity index (ECI), annual trends of both TAA and AF for utilization and in-hospital LOS. Charges and reimbursements for TAA were evaluated. Data was analyzed utilizing a Pearson’s Chi- Square analyses or Fischer’s exact test. A Chi-square test along with t-tests and Linger regression were also utilized.
Results:
A total of 21,433 patients were included. Patients undergoing TAA had greater ECI driven by arrythmias, congestive heart failure, diabetes mellitus, electrolyte disorders, iron deficiency anemia than patients undergoing AF (P < .001). TAA utilization increased from 21.5% to 49.4% (P < .0001). TAA patients had reduced LOS compared with AF patients (2.15 days vs. 3.11 days, P < .0001). TAA reimbursements remained stable while charges per patient increased from $40,203.48 in 2005, doubling by the end of 2013 to $86,208.59 (P < .0001).
Conclusions:
Utilization of TAA procedures increased in comparison to AF from 2005 to 2013. Patients undergoing TAA had reduced LOS in comparison to AF however reimbursement rates were uniform for both procedures. The authors do not state the reason for increase in utilization of TAA in comparison to AF. Limitations include no provided reasons for increase in TAA in comparison to AF. AF is noted to limit mobility gait and may lead to arthritis in adjacent joints. Therefore, recovery after AF is more tenuous. Post-operative recovery may impact patients’ surgical preference. One must account for surgeon bias when comparing these procedures. Finally, the authors examined LOS speculating that LOS for TAA was lower than in AF secondary to comorbidities associated in the AF population. One may argue that AF is selected secondary to comorbidities that are contraindicated in TAA: obesity, nerve damage, paralysis, or avascular necrosis. LOS may be affected by each surgeon’s postoperative protocol requiring longer observation. This study disregards socioeconomic status and living arrangements with respect to LOS at discharge planning. The reimbursement rate was uniform through both procedures. With newer implant designs, the curiosity remains if the reimbursement rate has ultimately been affected. Although it is ideal to shorten LOS, postoperative course is variable depending on level of OA. Surgeons must wholly evaluate each patient to make an appropriate procedure choice.