30-Day Outcomes After 3,285 Total Ankle Replacements: Favorable Safety Profiles for Both Primary and Revision Procedures

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: Total ankle replacement (TAR) has emerged as a reliable treatment for end-stage ankle arthritis, preserving joint motion and function. However, when a primary TAR fails, surgeons must choose between revision TAR (rTAR) and fusion. Although rTAR retains the benefits of the initial procedure, its short-term outcomes remain underexplored in large cohorts. This study leverages a nationally representative database to compare 30-day outcomes of primary versus revision TAR, with a focus on complication profiles, readmissions, and reoperations. Our objective is to determine whether rTAR carries a significantly higher risk, identify key factors influencing outcomes, and provide evidence-based guidance for surgical decision-making and patient selection, ultimately optimizing perioperative management in modern foot and ankle practice. Methods: Using the ACS-NSQIP database from January 2011 to December 2023, we conducted a retrospective cohort study of TARs. Primary TAR cases were identified by CPT code 27702 and rTAR cases by CPT code 27703. Patients with incomplete demographic or outcome data or emergent procedures were excluded. Variables collected included patient demographics (age, sex, BMI, race, smoking), comorbidities (diabetes, COPD, CHF, hypertension, steroid use, ASA classification), and peri-operative details. The primary outcomes were 30-day complications—categorized as major (cardiac events, MI, stroke, pulmonary embolism, sepsis, mortality) and minor (superficial/deep SSI, wound dehiscence, pneumonia, UTI, renal insufficiency)—as well as 30-day readmissions and reoperations. Continuous variables were compared using t-tests or Mann–Whitney U tests, and categorical variables with chi-square or Fisher’s exact tests. Multivariate logistic regression, adjusted for potential confounders and validated via propensity score analyses, identified independent predictors of adverse outcomes. Statistical significance was set at p< 0.05. Results: We identified 3,285 TAR procedures: 2,964 primary (90.2%) and 321 revision (9.8%). rTAR patients were significantly younger (62.8±11.2 vs. 64.5±10.2 years, p=0.016) with similar BMI (30.3±7.9 vs. 30.8±7.5 kg/m², p=0.471) and comorbidity profiles. Revision procedures required longer operative times (165.4±89.6 vs. 150.3±57.4 minutes, p=0.007) and had higher work RVUs (p < 0.001). Major complication rates were low and comparable (0.9% vs. 0.5%, p=0.452); however, overall, 30-day complications were significantly higher for revisions (5.9% vs. 2.7%, p=0.024), driven by increased superficial/deep SSI and wound dehiscence (each 1.2% vs. 0.3%, p=0.040). Readmissions were similar (1.9% vs. 1.4%, p=0.186), while rTAR had a nearly threefold higher reoperation rate (1.9% vs. 0.7%, p=0.028). Multivariate analysis confirmed revision status as an independent predictor of complications (OR 2.30, 95% CI 1.37–3.84, p=0.024). Conclusion: rTAR demonstrates a favorable 30-day safety profile similar to primary TAR, with low major complication and readmission rates. Although revisions exhibit a modestly higher overall complication rate—particularly for wound-related events—and a nearly threefold increased risk of reoperation, these risks remain acceptable when patients are meticulously selected and optimized. Our findings empower surgeons to counsel patients accurately, balancing the benefits of joint and motion preservation against minor increased risks. Ultimately, rTAR is a safe, effective option for failed primary TAR, reinforcing its role in modern foot and ankle practice and guiding future strategies to further improve patient outcomes.