Comparison of Early Postoperative outcomes and Work Relative Value Units-Based Compensation Following Primary versus Revision Total Ankle Arthroplasty

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Over the decades, advancements in implant design and surgical techniques for total ankle arthroplasty (TAA) have led to improved functional outcomes and the incidence of TAA has been increasing. However, this has also led to a rise in the incidence of revision TAA (rTAA). Revision surgery for TAA is a complex procedure that can carry a higher risk of postoperative complications compared to primary TAA. Despite the increasing frequency of rTAA, there is a still lack of data on its outcomes, especially the comparison with TAA. Furthermore, although rTAA involves greater surgical complexity and longer operative times, it remains unclear whether it is appropriately compensated. The goal of this study is to compare early postoperative outcomes and wRVU-based compensation between TAA and rTAA. Methods: The National Surgical Quality Improvement Program (NSQIP) database between 2013 and 2022 was utilized for this study. TAA and rTAA cases were identified using Current Procedural Terminology (CPT) codes 27702 and 27703. Patient demographics, comorbidities, and concomitant procedures were analyzed. Total wRVU was calculated by assigning 100% to the primary procedure and 50% to concomitant procedures. Primary outcomes included mortality, reoperation, and readmission, while secondary outcomes assessed postoperative complications such as wound infection, dehiscence, thromboembolic events, and pulmonary, cardiac, or renal complications. Compensation adequacy for rTAA was evaluated by comparing wRVUs, operative time (OT), wRVU per hour (wRVU/h), and reimbursement rates ($/hour) with those of TAA. Additionally, an analysis of covariance was conducted to account for the impact of complication rates on the assessment of compensation adequacy. The complications considered in this analysis included mortality, readmission, reoperation, wound complications, and thromboembolic events. Results: Total 2,418 TAA and 276 rTAA cases were identified. The incidence of both procedures has gradually increased since 2013, from 78 TAAs and 10 rTAAs to 362 TAAs and 37 rTAAs in 2022. TAA patients were significantly older (64.5 vs. 61.8 years, P<.001), with no significant differences in comorbidities. Preoperative open wounds/wound infections were higher in rTAA (2.9% vs. 0.3%, P<.001). There were no significant differences in primary outcomes or complications. rTAA involved more concomitant procedures (0.79 vs. 1.10, P=.001), with hardware removal, Achilles tendon lengthening, and bone grafting being most common. Compared to TAA, rTAA had significantly higher operative time (151.45 vs. 166.78, P=.003), wRVU (17.04 vs. 20.98, P<.001), wRVU/h (7.57 vs. 9.63, P<.001), and reimbursement($/h) (244.78 vs. 311.65, P<.001). Conclusion: The incidence of TAA and rTAA has been increasing. Although our study found no significant differences in early postoperative outcomes between TAA and rTAA, further long-term follow-up studies are necessary to draw more definitive conclusions, as the NSQIP database only provides perioperative outcomes within a 30-day timeframe. Regarding the adequacy of compensation, rTAA demonstrated appropriately higher wRVU-based compensation and these trends were maintained after adjusting for the rates of complication, reflecting its greater surgical time and complexity. Comparison of Early Postoperative outcomes and Work Relative Value Units-Based Compensation Following Primary versus Revision Total Ankle Arthroplasty