Abstract
Background:
Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies.
Methods:
The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria.
Results:
Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria.
Conclusion:
This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered.
Level of Evidence:
Level IV, review.
Keywords
Introduction
Total ankle arthroplasty (TAA) was first developed in the 1970s as an alternative to ankle arthrodesis for end-stage ankle arthritis. 11 Although early attempts at TAA had high complication rates, better implant design has led to improvements in outcomes.2,9,13 As such, utilization of TAA has continued to rise. Analysis of the Medicare database from 2005 to 2012 has shown a 16.37% annual growth rate in TAA utilization. 8 As utilization of TAA increases, payment and coverage become increasingly important topics for surgeons, hospitals, and commercial payers.
A variety of strategies have been employed by commercial payers to control the costs of medical services. In 2006, the Tax Relief and Health Care Act allowed Centers for Medicare and Medicaid Services (CMS) to retrospectively review claims of medical necessity for services based on region-specific Local Coverage Determinations (LCDs). 1 If claims were retrospectively found to not fulfill LCD criteria, compensation could be demanded in the form of physician payments and/or deductions from future reimbursements. 3 However, an analysis of LCD criteria for hip and knee arthroplasty in Florida found minimal and low level of evidence (LOE) references used to support criteria recommending conservative management and duration of conservative management. 3
Current commercial payers are forced to prospectively utilize coverage policies to determine medical necessity of procedures. However, this can limit and/or delay treatment for patients with severe pain or loss of functionality. This is especially true as coverage criteria for arthroplasty almost always specify that patients must have failed a period of conservative treatment. Previous studies in the total joint arthroplasty (TJA) and total shoulder arthroplasty (TSA) literature have found that such requirements for attempted nonoperative management are poorly supported both by the references in the coverage policy document and by available literature on the subject.1,17 More generally, these same studies have shown that the references used to support all commercial insurance coverage criteria for TJA and TSA tend to be of low level of evidence.1,17
The purpose of this study was to analyze commercial payer coverage policies for TAA in the United States and to characterize the references used to support these policies. To our knowledge, this is the first such study. We hypothesized that payer coverage documents would be supported by primarily low LOE references and would offer limited support for specific payer coverage criteria.
Materials and Methods
The top 11 national commercial health insurance payers for TAA were identified. A Google search was performed for each payer to find publicly available coverage policies pertaining to TAA. Search terms included “total ankle replacement” and “total ankle arthroplasty” followed by the individual payer name and the term “coverage policy.” For policies unable to be found through Google search, a phone call and email was sent to the company asking for coverage policy for TAA. A standardized review process was implemented for each policy. Policy documents were examined for references supporting coverage policies. Supporting references were then screened by title and/or abstract for relevance to TAA (as policy documents may cover multiple procedures). Exclusion criteria for references were irrelevance to TAA, full-text unavailable, and not in English language. Selected references were then categorized into type of reference, reviewed for level of evidence (LOE) per accepted published criteria, 19 and assessed for mention of specific coverage criteria. References were categorized into the following types of references: primary journal article, review article, expert opinion article, society guideline, governmental report or guideline, website, textbook, miscellaneous, or not found. Policy documents were analyzed for coverage criteria related to TAA, and a combined list of coverage criteria was created. The references were assessed for mention of criteria according to this combined list.
Results
Overall
The TAA coverage policies and associated references were obtained for 6 commercial payers (Aetna, Anthem, Cigna, Health Care Services Corporation, Highmark, United Healthcare). Coverage policies were not publicly accessible for the remaining 5 (Centene, Humana, Kaiser Permanente, The UPMC Health Plan, WellCare Health Plans). After screening of references and removal of duplicates, 278 unique references were analyzed, of which 40 full-texts were unavailable. One-hundred forty-five references (60.9%) were classified as primary journal articles, 65 (27.3%) were classified as review articles, 6 (2.5%) were classified as expert opinion, 7 (2.9%) were classified as society guidelines, 3 (1.3%) were classified as government reports/guidelines, 2 (0.8%) were classified as websites, and 10 (4.2%) were classified as miscellaneous (Table 1). LOE was level I in 4 references (1.7%), level II in 24 references (10.1%), level III in 71 references (29.8%), level IV in 108 references (45.4%), level V in 17 references (7.1%), and unable to be determined in 14 references (5.9%) (Table 2, Figure 1).
Reference Types by Payer and in Sum.
Abbreviation: HCSC, Health Care Services Corporation.
Reference Level of Evidence by Payer and in Sum.
Abbreviations: HCSC, Health Care Services Corporation; LOE, level of evidence.
Reference level of evidence by payer.
After analysis of all 6 commercial payer coverage criteria, the following combined list of coverage criteria was created: US Food and Drug Administration (FDA)-approved implant, skeletal maturity, failure of conservative management, severe pain, loss of function or mobility, advanced ankle arthritis, arthritis of adjacent joints, severe arthritis of contralateral ankle, arthrodesis of contralateral ankle, presence of inflammatory arthritis, and good lower extremity vascular perfusion. Table 3 displays the specific coverage criteria included by each commercial payer. References were examined for mention of these criteria. For failure of conservative management, references were examined for mention of duration of conservative management. Of the 238 references, 135 references (56.7%) mentioned an FDA-approved implant, 22 references (9.2%) mentioned skeletal maturity, 80 references (33.6%) mentioned severe pain, 74 references (31.1%) mentioned loss of function or mobility, 199 references (83.6%) mentioned advanced ankle arthritis, 22 references (9.2%) mentioned arthritis of adjacent joints, 18 references (7.6%) mentioned severe arthritis of contralateral ankle, 23 references (9.7%) mentioned arthrodesis of contralateral ankle, 139 references (58.4%) mentioned presence of inflammatory arthritis, 86 references (36.1%) mentioned good lower extremity vascular perfusion, and 91 references (38.2%) specified surgical candidacy. Only 6 references (2.5%) mentioned the duration of conservative treatment. Four references (1.7%) specified 6 months as length of conservative treatment, whereas 2 references (0.8%) specified 12 weeks as length of conservative treatment (Table 4, Figure 2).
Inclusion of Common Coverage Criteria by Commercial Payer.
Abbreviations: FDA, US Food and Drug Administration; HCSC, Health Care Services Corporation.
Number and Percentage of References Cited by Each Payer That Mention Their Specific Coverage Criteria.
Abbreviations: FDA, US Food and Drug Administration; HCSC, Health Care Services Corporation.
Number and percentage of references cited by each payer that mention their specific coverage criteria.
Aetna
Aetna had 115 references that were analyzed. Reference type and level of evidence can be found in Tables 1 and 2, respectively. Ten references (8.7%) mentioned arthritis of adjacent joints, 16 references (13.9%) mentioned severe arthritis of contralateral ankle, and 11 references (9.6%) mentioned arthrodesis of the contralateral ankle (Table 4, Figure 2). Two references (1.7%) mentioned the duration of conservative treatment, with both specifying 6 months (Table 4, Figure 2).
Anthem
Anthem had 50 references that were analyzed, none of which were cited within the text of the coverage policy. Five references (10.0%) mentioned arthritis of adjacent joints, 0 references (0%) mentioned severe arthritis of contralateral ankle, and 8 references (16.0%) mentioned arthrodesis of contralateral ankle (Table 4, Figure 2). One reference (2.0%) mentioned duration of conservative treatment of 6 months (Table 4, Figure 2).
Cigna
Cigna had 59 references that were analyzed, of which 10 were cited in the text of their coverage policy. Three references (5.1%) mentioned arthritis of adjacent joints, 4 references (6.8%) mentioned severe arthritis of the contralateral ankle, and 2 references (3.4%) mentioned arthrodesis of the contralateral ankle (Table 4, Figure 2). Two references (3.4%) mentioned the duration of conservative treatment, with both specifying 6 months (Table 4, Figure 2).
Health Care Services Corporation
Health Care Services Corporation had 33 references that were analyzed. Eight of these references were cited in the full text of their coverage policy. Three references (9.1%) mentioned arthritis of adjacent joints, 3 references (9.1%) mentioned severe arthritis of contralateral ankle (Table 4, Figure 2). Two references (6.1%) mentioned the duration of conservative treatment, with both specifying 12 weeks (Table 4, Figure 2).
Highmark
Highmark had 15 references that were analyzed. None were cited in the full text of the coverage policy. The most recent reference was published in 2010. One reference (6.7%) mentioned arthritis of adjacent joints, 0 references (0%) mentioned severe arthritis of the contralateral ankle, and 0 references (0%) mentioned arthrodesis of the contralateral ankle (Table 4, Figure 2). One reference (6.7%) mentioned duration of conservative treatment of 6 months (Table 4, Figure 2).
United Healthcare
United Healthcare had 6 references that were analyzed, all of which were cited in the full text of the coverage policy. United Healthcare did not provide coverage criteria within their coverage policy. Rather, in their coverage policy, they referenced an independent contractor who provides their coverage criteria; however, this document was not publicly accessible. Two references (33.3%) mentioned arthritis of adjacent joints, 0 references (0%) mentioned severe arthritis of the contralateral ankle, and 0 references (0%) mentioned arthrodesis of the contralateral ankle (Table 4, Figure 2). One reference (16.7%) mentioned duration of conservative treatment of 6 months (Table 4, Figure 2).
Discussion
The results of this study demonstrate that in their coverage policies for TAA, commercial insurance payers cite poor quality references, occasionally cite their references improperly in the policy document, and are forced to rely on low–level of evidence studies to formulate their specific coverage criteria. This study found that of the 238 unique articles screened, most (60.9%) were primary journal articles and only 11.8% were level I or level II evidence. Analysis of payer coverage criteria demonstrated a high degree of homogeny among payers. Finally, this study found that the references cited by commercial payers rarely investigate their specific coverage criteria.
Our results show that insurance companies cite primary journal articles most frequently in their coverage policies for TAA and that they most frequently cite studies of level IV evidence (45.4%). Our findings are consistent with prior studies in the total joint arthroplasty (TJA) and total shoulder arthroplasty (TSA) literature. In a 2021 study by Austin et al 1 examining commercial insurance payer coverage policies for TJA, the authors found that of the 282 documents reviewed, 45.8% were primary journal articles, 14.2% were level I or II evidence, and only 41.2% of sources were applicable to patients who were candidates for TJA. Sudah et al conducted a similar study in the TSA literature. They also found that primary journal articles (n = 70; 59.3%) were the most frequently cited and that most references were of level IV evidence (n = 60; 52.2%). 17 Only 6 (5.2%) of the sources they analyzed were level I or II evidence. 17 Of the 238 unique references analyzed in our study, only 4 (1.7%) were level I evidence and 24 (10.1%) were level II. Thus, it appears that commercial payers tend to support their coverage policies for TAA with low level evidence. Although there have been several recent high–level of evidence studies,5,6,12,14,16 level I and II studies on TAA do remain relatively scarce, which could explain this finding.
By examining coverage criteria among the 6 payers analyzed, this study demonstrated close similarities across the different commercial insurance payers. This could be ascribed to a common consensus on indications for the procedure; however, given the lack of high–level of evidence studies on TAA, there is some concern that insurance companies may not have the necessary information to justify both their specific indications and such broad consensus. These adopted criteria have the potential to perpetuate inaccurate indications for TAA; nevertheless, the solution to this problem lies in more high–level of evidence studies on the subject.
As in hip, knee, and shoulder arthroplasty, osteoarthritis is the most common condition requiring TAA. Analysis of insurance coverage criteria for these arthroplasty procedures reveals they are closely related and all require some period of conservative treatment before insurance companies with coverage arthroplasty.1,17 Previous research has shown that this period of conservative management is not well supported in the hip, knee, and shoulder arthroplasty literature.1,17 The same appears to be true for TAA.
All of the payers analyzed included a criterion specifying the need to have failed conservative management. Four payers (Aetna, Cigna, HCSC, Highmark) require patients to have failed 6 months of conservative management and 1 payer (Anthem) requires they fail 3 months. However, there is little support for the efficacy of conservative management in severe ankle arthritis. A 2013 paper by Labib et al 7 found, after an extensive review of the literature, that there were no articles specifically investigating the nonoperative management of ankle arthritis. A review of literature for this study also revealed a lack of studies on conservative management of ankle arthritis. The results of our study also support the notion that failure of conservative management is not a common consideration when investigating ankle arthritis, because among the 238 articles analyzed for this study, only 6 mentioned that patients included in the study had failed nonoperative management. Four of these articles had a time period of 6 months and two a time period of 3 months.
Another common coverage criterion required patients to have documented severe arthritis of the contralateral ankle or arthrodesis of the contralateral ankle; however, this criterion is rarely mentioned in the text of coverage policy references. In combination with the fact that around 70% of ankle arthritis cases are posttraumatic, this criterion makes it seem as if patients with unilateral posttraumatic ankle arthritis will not be covered for TAA 10 and instead forced to undergo arthrodesis of the affected joint. Although, in reality, many of these patients end up receiving TAA, this criterion remains somewhat misleading.
Research comparing outcomes between ankle arthrodesis and TAA have demonstrated similar patient-reported outcomes between the two with slightly high rates of reoperation in TAA patients.6,18 However, TAA does appear to offer certain advantages that may be beneficial for some patients. A 2020 study by Sanders et al 15 comparing gait and stair ascent between patients with TAA and arthrodesis found sagittal ankle range of motion during level walking, forefoot-tibia motion, and hindfoot-tibia motion were significantly greater in the TAA group (all P < .05). During stair ascent, sagittal ankle ROM, forefoot-tibia, and hindfoot-tibia motion were also all significantly greater (all P < .05) in the TAA group. 15 Analyzing gait in TAA patients and ankle arthrodesis patients, Flavin et al 4 found TAA patients had better sagittal dorsiflexion (P = .001) and vertical ground force reaction curve more similar to controls; however, arthrodesis had superior coronal plane eversion (P = .01). Given the apparent biomechanical differences produced by the 2 procedures, patients and physicians should be able to choose between the two and select the better procedure for each individual patient.
This study had several limitations. The first was that we were only able to access the coverage policy document for 6 of the 11 investigated payers. Nevertheless, the 6 included payers cover more than 100 million patients in the United States, which makes the results of this study relevant to a substantial proportion of the population. We also believe it is possible, given the homogeneity of criteria among payers, that findings for the payers analyzed may be representative of those payers we did not analyze. Another limitation is that we were unable to access the specific coverage criteria for United Healthcare. United Healthcare contracts its coverage criteria to an independent contractor and the criteria were thus locked behind a paywall and not accessible to the public. Given the relative lack of level I and II studies investigating TAA, we were also limited in our ability to draw conclusions based on study level of evidence referenced by commercial payers. Finally, we were unable to access the full texts for 40 of the sources found in the references of the commercial payer documents; however, the majority of these sources were either published prior to 1990 or not published in English.
This study demonstrates that commercial insurance payer coverage policies for TAA cite primarily low-level evidence and must rely on these studies when formulating their coverage criteria for the procedure. This study also shows that coverage criteria are highly similar among the included payers. Our analysis highlights the importance of continuing to pursue high–level of evidence research on TAA in order to allow physicians and insurance companies to make better-informed decisions as to the appropriate indications for the procedure. Given the improved success of third-generation ankle implants, it is key that we both identify appropriate candidates and work to ensure their insurance covers the procedure.
Supplemental Material
sj-pdf-1-fao-10.1177_24730114241239310 – Supplemental material for Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty
Supplemental material, sj-pdf-1-fao-10.1177_24730114241239310 for Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty by Jacob L. Kotlier, Amir Fathi, Meng-Yung Ong, Josh M. Yazditabar, Ethan E. Panoussi, Cory K. Mayfield, Frank A. Petrigliano, Joseph N. Liu, Alexander B. Peterson and Eric W. Tan in Foot & Ankle Orthopaedics
Footnotes
Appendix
| Commercial Payer | Reference (Title) | Year | Type of Reference |
|---|---|---|---|
| Aetna | Total ankle arthroplasty | 2010 | Expert opinion |
| Aetna | Design comparison of the INBONE I versus INBONE II total ankle system | 2013 | Expert opinion |
| Aetna | Total ankle replacements: clinical effectiveness and a review of the guidelines | 2008 | Government guideline |
| Aetna | Eclipse total ankle implant: summary of safety and effectiveness | 2006 | Government report |
| Aetna | Scandinavian Total Ankle Replacement System: summary of safety and effectiveness | 2009 | Miscellaneous |
| Aetna | Topez total ankle replacement | 2005 | Miscellaneous |
| Aetna | Salto Talaris total ankle prosthesis | 2009 | Miscellaneous |
| Aetna | Inbone II Total Ankle System: summary of safety and effectiveness | 2010 | Miscellaneous |
| Aetna | Infinity total ankle replacement | 2014 | Miscellaneous |
| Aetna | Zimmer trabecular metal total ankle | 2012 | Miscellaneous |
| Aetna | The INBONE II total ankle system | 2013 | Primary journal article |
| Aetna | Comparison of total ankle arthroplasty and ankle arthrodesis in end-stage hemophilic arthropathy | 2020 | Primary journal article |
| Aetna | Total ankle arthroplasty: new concepts and approaches | 1991 | Primary journal article |
| Aetna | Total ankle replacement in obese patients: component stability, weight change, and functional outcome in 118 consecutive patients | 2011 | Primary journal article |
| Aetna | The Agility total ankle arthroplasty: a concise follow-up at a minimum of 20 years | 2021 | Primary journal article |
| Aetna | Functional outcome of meniscal-bearing total ankle replacement: a gait analysis study | 2008 | Primary journal article |
| Aetna | Long-term follow-up of Bologna-Oxford (BOX) total ankle arthroplasty | 2021 | Primary journal article |
| Aetna | The Salto total ankle arthroplasty: survivorship and analysis of failures at 7 to 11 years | 2011 | Primary journal article |
| Aetna | Ankle function and sports activity after total ankle arthroplasty | 2009 | Primary journal article |
| Aetna | The impact of obesity on the outcome of total ankle replacement | 2015 | Primary journal article |
| Aetna | Ten-year evaluation of cementless Buechel-Pappas meniscal bearing total ankle replacement | 2003 | Primary journal article |
| Aetna | New Jersey low contact stress total ankle replacement: Biomechanical rationale and review of 23 cementless cases | 1988 | Primary journal article |
| Aetna | Radiostereometric analysis of the double-coated STAR total ankle prosthesis: a 3-5 year follow-up of 5 cases with rheumatoid arthritis and 5 cases with osteoarthrosis | 2005 | Primary journal article |
| Aetna | The surgical treatment for degenerative disease of the ankle | 2000 | Primary journal article |
| Aetna | Complications of total ankle replacement | 2002 | Primary journal article |
| Aetna | Relationship between body mass index and complications in total ankle arthroplasty: A single surgeon’s experience in ninety-seven replacements | 2018 | Primary journal article |
| Aetna | Quality of life in bilateral vs. unilateral end-stage ankle arthritis and outcomes of bilateral vs. unilateral total ankle replacement | 2017 | Primary journal article |
| Aetna | Evaluation of the early result of Smith total ankle replacement | 1980 | Primary journal article |
| Aetna | Total ankle replacement versus ankle arthrodesis for patients aged 50-85 years with end-stage ankle osteoarthritis: the TARVA RCT | 2023 | Primary journal article |
| Aetna | The effect of obesity on functional outcomes and complications in total ankle arthroplasty | 2015 | Primary journal article |
| Aetna | Ankle arthroplasty with preoperative coronal plane deformity: short-term results | 2004 | Primary journal article |
| Aetna | Patient-specific instrumentation vs standard referencing in total ankle arthroplasty: a comparison of the radiologic outcome | 2022 | Primary journal article |
| Aetna | Long-term results of total ankle replacement | 1986 | Primary journal article |
| Aetna | The Swedish Ankle Arthroplasty Register: an analysis of 531 arthroplasties between 1993 and 2005 | 2006 | Primary journal article |
| Aetna | HINTEGRA revision arthroplasty for failed total ankle prostheses | 2013 | Primary journal article |
| Aetna | A New Zealand national joint registry review of 202 total ankle replacements followed for up to 6 years | 2007 | Primary journal article |
| Aetna | Clinical outcomes of total ankle arthroplasty with total talar prosthesis | 2019 | Primary journal article |
| Aetna | The Scandinavian Total Ankle Replacement: survivorship at 5 and 8 years comparable to other series | 2010 | Primary journal article |
| Aetna | Revision of STAR total ankle replacement to hybrid AES-STAR total ankle replacement - a report of two cases | 2009 | Primary journal article |
| Aetna | Ankle arthroplasty in patients younger and older than 50 years: a prospective series with long-term follow-up | 2000 | Primary journal article |
| Aetna | Severe periprosthetic osteolytic lesions after the Ankle Evolutive System total ankle replacement | 2009 | Primary journal article |
| Aetna | Total ankle arthroplasty incorporating a total talar prosthesis: a comparative study against the standard total ankle arthroplasty | 2019 | Primary journal article |
| Aetna | Revision rates after total ankle arthroplasty in sample-based clinical studies and national registries | 2011 | Primary journal article |
| Aetna | Total ankle replacement in rheumatoid arthritis | 1984 | Primary journal article |
| Aetna | Analysis of ankle range of motion and functional outcome following total ankle arthroplasty | 2010 | Primary journal article |
| Aetna | Total ankle arthroplasty versus ankle arthrodesis—a comparison of outcomes over the last decade | 2017 | Primary journal article |
| Aetna | Comparison of intermediate-term outcomes of total ankle arthroplasty in patients younger and older than 55 years | 2019 | Primary journal article |
| Aetna | Transfibular total ankle arthroplasty: a new reliable procedure at five-year follow-up | 2022 | Primary journal article |
| Aetna | Malleolar fracture after total ankle arthroplasty: a comparison of two designs | 2004 | Primary journal article |
| Aetna | Total ankle replacement by the Ankle Evolution System: medium-term outcome | 2010 | Primary journal article |
| Aetna | Clinical-radiological outcomes and complications after total ankle replacement through a lateral transfibular approach: a retrospective evaluation at a mid-term follow-up | 2021 | Primary journal article |
| Aetna | Safety of outpatient total ankle arthroplasty vs traditional inpatient admission or overnight observation | 2017 | Primary journal article |
| Aetna | Total ankle replacement: early experiences with STAR prosthesis. | 2005 | Primary journal article |
| Aetna | Habitual physical activity and sports participation after total ankle arthroplasty | 2008 | Primary journal article |
| Aetna | Total ankle arthroplasty versus ankle arthrodesis: a comparative analysis of arc of movement and functional outcomes | 2016 | Primary journal article |
| Aetna | Ankle replacement versus arthrodesis: a comparative gait analysis study | 2008 | Primary journal article |
| Aetna | Trends in the use of total ankle replacement and ankle arthrodesis in the United States Medicare population | 2013 | Primary journal article |
| Aetna | Total ankle arthroplasty: a unique design. Two to twelve-year follow-up | 1998 | Primary journal article |
| Aetna | Trends in treatment of advanced ankle arthropathy by total ankle replacement or ankle fusion | 2014 | Primary journal article |
| Aetna | Prospective controlled trial of STAR total ankle replacement versus ankle fusion: initial results | 2009 | Primary journal article |
| Aetna | Effect of Obesity on Total Ankle Arthroplasty Outcomes | 2016 | Primary journal article |
| Aetna | Total ankle arthroplasty using biological fixation components compared to ankle arthrodesis | 1987 | Primary journal article |
| Aetna | Perioperative complications of the Agility total ankle replacement in 50 initial, consecutive cases | 2006 | Primary journal article |
| Aetna | Total ankle arthroplasty versus ankle arthrodesis. Comparison of sports, recreational activities and functional outcome | 2011 | Primary journal article |
| Aetna | Short-term results of our first 49 Scandinavian Total Ankle Replacements (STAR) | 2008 | Primary journal article |
| Aetna | Early prospective clinical results of a modern fixed-bearing total ankle arthroplasty | 2013 | Primary journal article |
| Aetna | Polyethylene fracture following STAR ankle arthroplasty: a report of three cases | 2009 | Primary journal article |
| Aetna | Preference-based quality of life of end-stage ankle arthritis treated with arthroplasty or arthrodesis | 2010 | Primary journal article |
| Aetna | Cost-effectiveness analysis of total ankle arthroplasty | 2004 | Primary journal article |
| Aetna | Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty | 2007 | Primary journal article |
| Aetna | Complications and failure after total ankle arthroplasty | 2004 | Primary journal article |
| Aetna | Intermediate to long-term clinical outcomes and survival analysis of the Salto Mobile Bearing total ankle prothesis | 2022 | Primary journal article |
| Aetna | Reoperation and patient satisfaction after the Mobility total ankle arthroplasty | 2012 | Primary journal article |
| Aetna | Ankle arthroplasty: a comparative study of cemented metal and uncemented ceramic prostheses | 1990 | Primary journal article |
| Aetna | Total ankle arthroplasty in rheumatoid arthritis: a long-term follow-up study | 1988 | Primary journal article |
| Aetna | Clinical and radiological outcomes of transfibular total ankle arthroplasty | 2019 | Primary journal article |
| Aetna | Sports and recreation activity of ankle arthritis patients before and after total ankle replacement | 2006 | Primary journal article |
| Aetna | The feasibility of total ankle prosthesis for severe arthropathy in hemophilia and prothrombin deficiency | 2006 | Primary journal article |
| Aetna | Total ankle replacement: medium-term results in 200 Scandinavian total ankle replacements | 2008 | Primary journal article |
| Aetna | A randomized, controlled trial of two mobile-bearing total ankle replacements | 2009 | Primary journal article |
| Aetna | Clinical comparison of two total ankle replacements | 2000 | Primary journal article |
| Aetna | Long-term follow-up of the Conaxial (Beck-Steffee) total ankle arthroplasty | 1992 | Primary journal article |
| Aetna | A systematic review of intermediate-term outcomes and failure rates for total ankle replacements: an Asian perspective | 2013 | Review |
| Aetna | Surgical procedures in patients with hemophilic arthropathy of the ankle | 2016 | Review |
| Aetna | Total ankle replacement | 2015 | Review |
| Aetna | Total ankle arthroplasty in France | 2010 | Review |
| Aetna | Current concepts in the management of ankle osteoarthritis: a systematic review | 2015 | Review |
| Aetna | Total ankle arthroplasty: a long-term review of the London Hospital experience | 1985 | Review |
| Aetna | Total ankle replacement: why, when and how | 2010 | Review |
| Aetna | Efficacy of total ankle replacement with meniscal-bearing devices: a systematic review and meta-analysis | 2006 | Review |
| Aetna | Cost-effectiveness analysis of total ankle arthroplasty | 2005 | Review |
| Aetna | High revision and reoperation rates using the Agility™ total ankle system | 2012 | Review |
| Aetna | Revision total ankle replacement: An early look at agility to INBONE | 2011 | Review |
| Aetna | Total ankle arthroplasty in the rheumatoid patient | 2010 | Review |
| Aetna | Management of failures of total ankle replacement with the agility total ankle arthroplasty | 2013 | Review |
| Aetna | Ankle arthritis: review of diagnosis and operative management | 2014 | Review |
| Aetna | Current concepts review: total ankle arthroplasty | 2008 | Review |
| Aetna | Total ankle replacement | 2003 | Review |
| Aetna | Total ankle arthroplasty versus ankle arthrodesis for the treatment of end-stage ankle arthritis: a meta-analysis of comparative studies | 2016 | Review |
| Aetna | Total ankle arthroplasty with the Agility prosthesis: Clinical and radiographic evaluation | 2006 | Review |
| Aetna | Modern total ankle arthroplasty versus ankle arthrodesis: a systematic review and meta-analysis | 2020 | Review |
| Aetna | Posttraumatic ankle arthritis: an update on conservative and surgical management | 2007 | Review |
| Aetna | Patient-specific instrumentation in total ankle arthroplasty | 2022 | Review |
| Aetna | Post-operative management after total ankle arthroplasty: a systematic review of the literature | 2022 | Review |
| Aetna | Total ankle arthroplasty | 2011 | Review |
| Aetna | Avoiding and managing complications of the Agility Total Ankle Replacement system | 2006 | Review |
| Aetna | Total ankle replacement revisited | 2000 | Review |
| Aetna | Physical therapy management of patients with total ankle replacement | 1980 | Review |
| Aetna | Efficacy of total ankle replacement with meniscal-bearing devices: a systematic review and meta-analysis | 2005 | Review |
| Aetna | Total ankle replacement. Design evolution and results | 2010 | Review |
| Aetna | The mid-term outcome of total ankle arthroplasty and ankle fusion in rheumatoid arthritis: a systematic review | 2013 | Review |
| Aetna | A brief history of total ankle replacement and a review of the current status | 2007 | Review |
| Aetna | Patient-specific instrumentation (PSI) in total ankle arthroplasty: a systematic review | 2021 | Review |
| Aetna | Total ankle arthroplasty: a modern perspective | 2009 | Review |
| Aetna | A systematic review of outcome and failure rate of uncemented Scandinavian total ankle replacement | 2011 | Review |
| Aetna | Salvage after complications of total ankle arthroplasty | Unable to access | |
| Aetna | Total ankle arthroplasty: indications, results, and biomechanical rationale | Unable to access | |
| Aetna | Computer assisted surgery for total knee arthroplasty | Unable to access | |
| Aetna | Posttraumatic ankle arthrosis | Unable to access | |
| Aetna | Perspective on total ankle replacement | Unable to access | |
| Aetna | Total ankle arthroplasty: a procedural review | Unable to access | |
| Aetna | Mobile- and fixed-bearing total ankle prostheses: is there really a difference? | Unable to access | |
| Aetna | Our experience with AES total ankle replacement | Unable to access | |
| Aetna | Total ankle arthroplasty | 2002 | Unable to access |
| Aetna | Uncemented STAR total ankle prostheses | 2004 | Unable to access |
| Aetna | The effect of body mass index on outcomes after total ankle replacement | 2009 | Unable to access |
| Aetna | Preliminary report of a hybrid total ankle arthroplasty combining a stemmed intramedullary tibial component with chamfer-cut talar dome | 2021 | Unable to access |
| Aetna | Infinity ankle arthroplasty early Latin-America experience and patient outcomes | 2023 | Unable to access |
| Aetna | Survivorship and clinical evaluation of cementless, meniscal-bearing total ankle replacements | 1992 | Unable to access |
| Aetna | Osteoarthritis of the ankle: the role of arthroplasty | 2008 | Unable to access |
| Aetna | Design features of current total ankle replacements: implants and instrumentation | 2008 | Unable to access |
| Aetna | Total ankle arthroplasty: a review of 37 cases | 1988 | Unable to access |
| Aetna | Biomechanics of the ankle joint: a perspective on total ankle replacement | 2000 | Unable to access |
| Aetna | Clinical study of total ankle replacement with gait analysis: a preliminary report | 1979 | Unable to access |
| Aetna | Total ankle replacement: a surgical discussion. Part I: Replacement systems, indications, and contraindications | 2000 | Unable to access |
| Aetna | Total ankle replacement: a surgical discussion. Part II: The clinical and surgical experience | 2000 | Unable to access |
| Aetna | Clinical and radiographic outcomes of revision total ankle arthroplasty using the INBONE II prosthesis | 2022 | Unable to access |
| Aetna | Total ankle replacement in rheumatoid arthritis: a preliminary review of 28 arthroplasties in 24 patients | 1983 | Unable to access |
| Aetna | Survivorship analysis of the Mayo total ankle arthroplasty | 1994 | Unable to access |
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Abbreviation: HCSC, Health Care Services Corporation.
Ethical Approval
Ethical approval was not sought for the present study because this manuscript did not involve human subjects research.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
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