Abstract
Research Type:
Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies
Introduction/Purpose:
Total ankle replacement (TAR) has become commonplace for treating end-stage ankle osteoarthritis. While outcomes are well-described for younger- and middle-aged patients, the short-term outcomes in older patients have not been thoroughly explored, particularly in cases of revision. With the median age of TAR patients being 63 years, geriatric patients (age > 65) make up a considerable portion of TAR operations. Further, revision TAR in this age group continues to increase, as more cases are performed on younger- and middle-aged patients. Therefore, in this database study, primary and revision TAR cases in elderly patients were examined to determine the possible risk of adverse events in each group.
Methods:
In this National Surgical Quality Improvement Program (NSQIP) database study, we included all primary and TAR cases in elderly patients (age > 65 years) from 2010 to 2023. Cases were identified using Current Procedural Terminology (CPT) codes: the primary group included the codes 27702 and 27703, while the revision TAR group included 27704, 27705, 27707, and 27709. After identifying the relevant cases, groups were matched 1:1 by nearest neighbor propensity score to balance baseline characteristics (age, BMI, sex, race, ASA class, and key comorbidities). For statistical analysis, continuous variables were compared using the Wilcoxon test, and categorical variables were compared using the chi-square test. Finally, the risk of short-term complications for both groups was assessed via odds ratio calculations.
Results:
After matching, a total of 227 patients were in each group. Revision cases had significantly longer lengths of hospital stay (1.84 vs. 3.66 days, p < 0.001), higher rates of adverse events (3.5% vs. 15%, p < 0.001), and higher usage of intraoperative blood transfusion (0% vs. 7.5%, p < 0.001). Further, longer operating times posed a greater risk of adverse events in both groups (p < 0.5). Finally, type 1 diabetes was associated with a 3.66 times greater likelihood of adverse events in the revision group (p < 0.01) but was not a significant risk factor in primary TAR. For a summary of significant results, please see Table 1.
Conclusion:
In conclusion, revision TAR in elderly patients was associated with significantly higher rates of short-term adverse events compared to primary TAR. Diabetes emerged as a key risk factor in revision cases, warranting careful consideration in older patient populations with this comorbid condition. While longer operative time was a significant risk factor in both groups, this may reflect case complexity, with more challenging procedures inherently carrying higher complication risks. Despite these concerns, revision TAR remains a viable option in geriatric patients when performed with careful patient selection and perioperative management.
Table 1
Comparison of primary and revision total ankle replacement in elderly in terms of demographics, operative information, complications, and risk factors for adverse events