Total Ankle Arthroplasty vs Arthrodesis in an HbA 1c -Defined Diabetic Cohort: Lower 1- to 5-Year Structural Complication Rates in a Retrospective Propensity-Matched Study

Abstract

Background:

Patients with diabetes are at increased risk for postoperative complications after ankle arthrodesis (AA) and total ankle arthroplasty (TAA), yet few studies directly compare outcomes between these procedures in a matched diabetic cohort. This study evaluates outcomes of TAA vs AA in patients with diabetes with end-stage ankle arthritis.

Methods:

We performed a retrospective cohort study using the TriNetX Research Network. Adults undergoing primary TAA (Current Procedural Terminology [CPT] 27702) or ankle arthrodesis (CPT 27870 or 29899) between 2005 and 2025 were included. Diabetes was defined by hemoglobin A_1c (HbA_1c) ≥6.5% recorded at any point within 1 year prior to surgery. Propensity score matching (1:1) was performed using demographic and clinical covariates. Outcomes included 1-year infection and 1-, 3-, and 5-year structural complications and emergency department (ED) visits. ED visits captured all-cause encounters rather than ankle-specific presentations. The pre-specified primary endpoint was 1-year structural complication; secondary endpoints included infection at 1 year and ED visits and structural complications at 3 and 5 years, with FDR applied to secondary outcomes. Risk estimates, Kaplan-Meier analyses, and Benjamini-Hochberg false discovery rate (FDR) correction were applied.

Results:

After propensity score matching, 255 patients remained in each group. At 1 year, postoperative infection occurred in 5.5% of TAA patients and 9.4% of AA patients; this difference did not meet statistical significance after false discovery rate (FDR) adjustment. ED visits were more common in the AA cohort at 1, 3, and 5 years after FDR correction. Structural complications occurred more frequently in the AA cohort at 1 year (29.8% vs 15.3%; RR 0.51), 3 years (38.8% vs 20.0%; RR 0.52), and 5 years (39.6% vs 21.2%; RR 0.54), and these differences were statistically supported after FDR adjustment.

Conclusion:

In patients with a recorded HbA_1c ≥6.5% at any point within the previous year undergoing surgery for end-stage ankle arthritis, TAA demonstrated non-inferior structural complication rates across 1-, 3-, and 5-year follow-up without evidence of increased early infection risk after FDR adjustment.

Graphical Abstract

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