The Burden of Revision Total Ankle Replacement Has Markedly Increased from 2010 to 2020

Abstract

Category: Ankle Arthritis Introduction/Purpose: Total ankle replacement (TAR) surgery has steadily increased in recent decades. The aim of the current study was to investigate the evolving burden of revision surgery and risk factors and timing of revision or implant removal. We hypothesized that there has been an increase in revision TAR and explant surgeries in the past decade and that younger age and higher comorbidity burden are risk factors for revision and explant. Methods: Using the 2010-2020 PearlDiver M151Ortho dataset, this retrospective cohort study identified primary TAR, TAR revision, and TAR explant patients. This is a large national database containing billing claims information on over 151 million patients in the United States across all payer types and sites of care. Patient factors investigated included age, sex, and Elixhauser Comorbidity Index (ECI, a longitudinal measure of patient comorbidity burden generated using ICD-9 and ICD-10 diagnosis codes). Annual incidence for primary and revision TAR, and explant were recorded. Multivariate logistic regression analyses were performed to determine independent risk factors for revision TAR or explant relative to primary TAR. For explants, the eventual intervention by two years was analyzed. Ten-year timing and survival to revision or explant surgery following patient-matched unilateral TAR were characterized. Results: Over the study period, there were 10,531 primary, 1,218 revision, and 1,735 explant TARs (increasing by 310%, 398%, and 9.6%, respectively). Independent predictors of revision TAR included: younger age (odds ratio [OR] 1.29 per decade decrease) and higher ECI (OR 1.23 per 2-point increase) (p < 0.0001 for both). Independent predictors of explant surgery included: younger age (OR 1.80 per decade decrease, p< 0.0001), female sex (OR 1.17, p=0.0011), and higher ECI (OR 1.35 per 2-point increase, p< 0.0001). Explanted patients went on to arthrodesis (37.7%), amputation (26.1%), revision TAR (14.7%), or no identified procedure/other procedures (21.5%) within the subsequent two years. The 10-year implant survival rate following primary TAR was 91.8%. 73% and 83% of revisions and explants occurred in the first three years following index TAR, respectively. Conclusion: The burden of TAR revision has grown substantially over the past decade. Younger age, female sex, and higher patient comorbidity burden were associated with increased risk of revision or explant surgery. If explant is pursued, most went on to arthrodesis or amputation. These results suggest that care should be taken in patient selection for TAR to minimize the occurrence of revision and explant surgery. Treatment algorithms should be modified to optimize outcomes among patients who undergo explant or revision surgery.