Risk Factors for Post-Operative Complications and Reoperation in Patients undergoing Ankle Arthrodesis and Total Ankle Arthroplasty

Submission Type: Ankle Arthritis Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Total ankle arthroplasty (TAA) and ankle arthrodesis (AA) are two commonly used procedures in the treatment of end-stage ankle arthritis. Procedural complexity required to achieve the soft-tissue balance and plantigrade foot necessary for a successful patient outcome may require additional simultaneous adjunctive procedures versus temporally staged surgical management. There is little evidence evaluating the effect of additional procedures on patient outcomes and complication risks that could possibly advise surgeon management for simultaneous or temporally staged procedures. This study aims to evaluate adjunctive procedure number in AA/TAA and correlate to post-operative outcome. The primary outcome measures are increased complications, reoperations, and intraoperative data (blood loss, fluoroscopy time, tourniquet time). The secondary outcome was to detect differences in AA versus TAA via a matched cohort analysis. Methods: A retrospective chart review of AAs and TAAs performed at a single institution from the years 2008-2024 was performed utilizing CPT codes encapsulating both procedures. Patients were included if they received either AA or TAA within the assigned period and placed into two demographically matched patient groups. Chart review was undertaken to evaluate comorbidities, operative data, and post-operative outcome. Statistical analyses, including odds ratios, analysis of variance, and regression analysis were then performed. A priori power analysis revealed a minimum of 200 patients in each group would be required to detect an increase in complication or reoperation for the primary and secondary outcome. Results: 491 patients were initially identified. 455 remained after exclusion, of which 210 underwent AA and 245 underwent TAA. One patient underwent staged TAA conversion from AA. Mean patient age (67.7 years, TAA vs. 62.5 years, AA) and preoperative comorbidities (5.8, TAA vs. 4.8, AA) were significantly different between groups. TAA patients experienced a lower overall rate of complications (20%), and reoperation (8%) compared to AA (32% and 16%, respectively). As the number of adjunctive procedures increased, complication and reoperation rates in TAA patients also increased, but in AA patients the rates remained relatively constant. Procedure duration and tourniquet time were significantly longer in TAA. Additionally, regression analysis revealed specific comorbidities correlated to post-operative outcomes regardless of adjunctive procedural risk. Conclusion: Patients who undergo TAA, but not AA, have an increased risk of complication and reoperation as adjunctive procedures are added in a simultaneous surgical event. Adjunctive procedures seem to increase complication risk as each is added, thus complication risk mirrors case complexity. This is the first study to evaluate complication risk and adjunctive procedure number in TAA and AA with adequate statistical power. Surgeons should carefully consider planned surgical treatment to minimize perioperative surgical risk. Study limitations are problems common to retrospective reviews, including both selection and recall bias.