Variation in procedure selection for end stage ankle arthritis management in England

INTRODUCTION: End-stage ankle arthritis is a debilitating condition presenting with pain and functional limitations. Surgical management typically involves ankle arthrodesis (AA) or total ankle replacement (TAR). This study aimed to investigate demographic, socioeconomic, and clinical factors associated with receiving TAR versus AA in England. METHODS: A retrospective cohort analysis was conducted using Hospital Episode Statistics (HES) data for all elective AAs and TARs performed in England between April 2013 and March 2025. Patients aged 17 years and over were included. Multivariable logistic regression was used to assess associations between procedure type and patient-level factors. RESULTS: A total of 26,331 procedures were identified, comprising 8836 (33.6%) TARs and 17,495 (66.4%) AAs. Older age and female sex were independently associated with increased odds of TAR (age ≥80 years relative to 17-29 years: odds ratio (OR) 12.89, 95% confidence interval (CI) 9.86-17.29; female sex: OR = 1.46, 95% CI 1.36-1.56). Relative to no frailty, mild and moderate frailty increased the likelihood of TAR, whereas severe frailty reduced it (OR 0.51, 95% CI 0.37-0.71). Patients from less deprived areas were more likely to receive TAR (IMD 5th quintile relative to 1st quintile OR 1.40, 95% CI 1.25-1.58). Compared with White patients, those of Asian ethnicity were less likely to undergo TAR. CONCLUSION: Older age, female sex, lower deprivation, and mild-to-moderate frailty are associated with higher odds of TAR, while Asian ethnicity, higher deprivation and severe frailty are associated with reduced likelihood. These findings likely highlight patterns in clinical decision making, but may also suggest possible variation in access to ankle arthroplasty.