ORIGINAL RESEARCH |
https://doi.org/10.5005/jp-journals-10040-1280 |
End-stage Ankle Arthritis: Variations in the Current State of Practice of Asia-Pacific Foot and Ankle Surgeons
1Department of Orthopaedic Surgery, Gleneagles Medical Centre, Central Region, Singapore
2National Health Services, United Kingdom
3Department of Orthopaedic Surgery, Mount Elizabeth Novena Hospital, Central Region, Singapore
Corresponding Author: Chin Yik Tan, Department of Orthopaedic Surgery, Gleneagles Medical Centre, Central Region, Singapore, Phone: +6581812294, e-mail: chinyik_tan@yahoo.com
Received on: 30 November 2022; Accepted on: 25 December 2022; Published on: 07 July 2023
ABSTRACT
Background: This study is aimed to assess differences in the pattern of practice and choice of management of end-stage ankle arthritis among established Asia-Pacific foot and ankle surgeons.
Materials and methods: A survey was presented to fellowship trained foot and ankle surgeons registered with their respective national orthopedic professional societies practicing in the Asia-Pacific region. The e-mail-based survey contained eight questions and participation in the survey was entirely voluntary. A Microsoft Excel spreadsheet was used to collate the data and was subsequently analyzed using Windows-based statistical software. Multiple choice questions and visual analog scales were primarily used to gather demographic data and surgeons’ choice of managing end-stage ankle arthritis. Surgeons were also presented with open-ended questions to gather information about operation times and surgical treatment choices for a variety of clinical scenarios.
Results: The response rate to the survey was 100%. The practice pattern demographics of surgeons included in the study were primarily foot and ankle-focused. There was a varied response with regards to the number of total ankle replacements (TARs) carried out in the previous 1 year at the time of the survey, with 14 (67%) had not carried out any, two (10%) had carried out one ankle replacement, two (10%) had two ankle replacements, two (10%) had three ankle replacements, and one (5%) surgeon had carried out over five ankle replacements in the previous year. About six (75%) of the surgeons who answered surgical duration reported an average time of 120 minutes to perform the operation. Around four (80%) of the surgeons who answered associated procedures had also performed a soft tissue plication and osteotomy, and one (20%) had performed a soft tissue plication only. The number of surgeons who performed zero, one, two, three, and over five ankle fusions was the same as ankle replacements. In the question asking about the levels of satisfaction when performing a TAR, most (62.5%) had a satisfaction level of 7/10. Regarding open ankle fusion, the majority (61%) of surgeons had a satisfaction level of 8/10 or more. Most surgeons (81%) had a satisfaction level of 7/10 or above when performing an arthroscopic ankle fusion.
Conclusion: The prevalence of patients with end-stage ankle arthritis requiring surgery presenting to foot and ankle specialists in the region is low. Among specialists in the region, open ankle fusion remains the procedure of choice for the surgical management of end-stage ankle arthritis with the highest degree of surgeon comfort and satisfaction. Though infrequently performed, open ankle fusion, TAR, and arthroscopic ankle fusion are performed with a high degree of operator satisfaction in the minority of surgeons who do perform these procedures. Evidence in the modern literature for ankle fusions vs TAR is reflected by current practice trends in the Asia-Pacific region.
How to cite this article: Tan CY, Balogun-Lynch J, Thevendran G. End-stage Ankle Arthritis: Variations in the Current State of Practice of Asia-Pacific Foot and Ankle Surgeons. J Foot Ankle Surg (Asia-Pacific) 2023;10(3):108–113.
Source of support: Nil
Conflict of interest: Dr Gowreeson Thevendran is associated as the Editorial board members Asia Pacific of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of this Editorial board members Asia Pacific and his research group.
Keywords: Ankle arthritis, Arthroscopic ankle fusion, Asia-Pacific, Foot and ankle surgeons, Total ankle replacement
INTRODUCTION
End-stage ankle arthritis remains a prevalent and debilitating condition, leading to functional limitations and reduced quality of life for patients.1,2 Glazebrook et al. found the impact of end-stage ankle arthritis on patients’ pain, quality of life, and function to be at least as severe as end-stage hip arthritis.3 The best form of surgical treatment for end-stage ankle arthritis continues to be regularly debated among the foot and ankle surgeon community. One of the main issues is deciding whether to perform a joint-sparing or joint-destructive procedure for patients with end-stage ankle arthritis.4 Open ankle fusion has been the gold standard surgical procedure for many years. However, more recently, TARs are being performed.4,5 Initially, TARs had poor early results, but with improvements in design, they are now becoming a popular alternative to ankle arthrodesis.4,6 No study in the literature has specifically looked at the current state of managing end-stage ankle arthritis in the Asia-Pacific region. The purpose of this study was to identify the current standard of practice for the surgical management of end-stage ankle arthritis in the Asia-Pacific region among fellowship trained foot and ankle surgeons.
MATERIALS AND METHODS
A survey (appendix 1) was presented to fellowship trained trained foot and ankle surgeons registered with their respective national orthopedic professional societies practicing in the Asia-Pacific region. The e-mail-based survey contained eight questions and participation in the survey was entirely voluntary. A Microsoft Excel spreadsheet was used to collate the data and was subsequently analyzed using Windows-based statistical software. Multiple choice questions and visual analog scales were primarily used to gather demographic data and surgeons’ choice of managing end-stage ankle arthritis. Surgeons were also presented with open-ended questions to gather information about operation times and surgical treatment choices for a variety of clinical scenarios.
RESULTS
The response rate to the survey was 100%. The practice pattern demographics of surgeons included in the study were primarily foot and ankle-focused, with 14 surgeons (66%) reporting that foot and ankle surgery comprised >75% of their practice. All foot and ankle surgeons included in the study reported their location of practice within the Asia-Pacific region. Around five practiced in Thailand (29%), one in Vietnam (4%), five in Singapore (24%), four in Hong Kong (19%), three in Malaysia (14%), two in Indonesia (9%), and one in Sri Lanka (5%) (Fig. 1).
Fig. 1: Countries of respondents
The questionnaire surveyed surgeons about their usual referral route for patients. The majority of surgeons’ (43%) usual referral route was via self-referral. Around six (29%) were usually referred patients from orthopedic colleagues and six (29%) from general practitioners. The least common route of referral to foot and ankle surgeons was from other physicians (14%).
There was a varied response with regards to the number of TARs carried out in the previous 1 year at the time of the survey (Fig. 2), with 14 (67%) had not carried out any, two (10%) had carried out one ankle replacement, two (10%) had two ankle replacements, two (10%) had three ankle replacements, and one (5%) surgeon had carried out over five ankle replacements in the previous year.
Fig. 2: Number of TARs performed with the respective percentage of respondents
The question asking foot and ankle surgeons their average time for performing a TAR had a response rate of 38% (n = 8). About six (75%) of the surgeons that answered this question reported an average time of 120 minutes to perform the operation.
When asked about associated procedures carried out when performing a primary TAR, 24% (n = 5) of surgeons responded. Of these, four (80%) had also performed a soft tissue plication and osteotomy. Only one (20%) had performed a soft tissue plication only.
Similar to the number of TARs performed, there was a varied response with regard to the number of ankle fusions in the previous year (Fig. 3). A total of 14 (67%) of the foot and ankle surgeons had not performed any ankle fusions in the last 1 year at the time of the survey. About two (10%) had performed one, two, or three ankle fusions, respectively, in the previous year. One (5%) had performed over five ankle fusions in the last year.
Fig. 3: Number of ankle fusions performed with the respective percentage of respondents
The question asking about the levels of satisfaction foot and ankle surgeons have when performing a TAR had a response rate of 38% (n = 8). Of the surgeons that responded, very few (5%) had a high (9/10) level of satisfaction with the procedure. Most (62.5%) had a satisfaction level of 7/10, and two (25%) had the lowest satisfaction level of 6/10 associated with the procedure (Fig. 4).
Fig. 4: Visual analog scale of satisfaction index when performing TARs (0–10)
Substantially more surgeons, 86% (n = 18), answered the question investigating surgeons’ levels of satisfaction when performing open ankle fusions. Of these, the majority (61%) of foot and ankle surgeons had a satisfaction level of 8/10 or more. Only one (6%) of the surgeons had a level of satisfaction of 2/10 when performing open ankle fusions (Fig. 5).
Fig. 5: Visual analog scale of satisfaction index when performing open ankle fusions (0–10)
About 52% (n = 11) of surgeons answered the question of satisfaction levels when performing arthroscopic ankle fusion. Most surgeons, 81% (n = 9), had a satisfaction level of 7/10 or above when performing an ankle fusion using the arthroscopic technique (Fig. 6).
Fig. 6: Visual analog scale of satisfaction index when performing arthroscopic ankle fusions (0–10)
The majority of surgeons (81%) answered the question investigating levels of satisfaction when performing a hindfoot fusion. This procedure had a high level of satisfaction when performed, with 88% of surgeons having a satisfaction of 7/10 or above with the procedure (Fig. 7).
Fig. 7: Visual analog scale of satisfaction index when performing hindfoot fusions (0–10)
Surgeons were presented with four hypothetical scenarios and asked about their management choice. The majority of surgeons (76%) would have managed the 35-year-old patient with functional pain and pantalar arthritis (Fig. 8) with an ankle fusion. Only one (5%) opted for a TAR and one (5%) conservative treatment, respectively. Ankle fusion was also the most likely management choice for the 45-year-old patient with post-traumatic arthritis (Fig. 9), with 18 (86%) of the surgeons choosing this option. With regards to the 55-year-old female with functional pain, pantalar arthritis, and varus deformity (Fig. 10), surgeons were only slightly more likely to choose an ankle fusion (47%) over a TAR (41%). Around 12% of surgeons chose to treat the patient in scenario three with a supramalleolar osteotomy. Finally, with regards to the 65-year-old patient with rheumatoid arthritis, subtalar arthritis, and minimal deformity (Fig. 11), TAR was the most popular choice of treatment (62%) compared to performing an ankle fusion (33%). Conservative treatment was the management choice for 5% of surgeons.
Fig. 8: Response to the clinical scenario
Fig. 9: Response to the clinical scenario
Fig. 10: Response to the clinical scenario
Fig. 11: Response to the clinical scenario
DISCUSSION
Surgical management of end-stage ankle arthritis among foot and ankle surgeons in the Asia-Pacific region has not been investigated previously. This survey gives an overview of the current state of practice in the region, primarily with regard to what procedures surgeons are performing as a means of treating end-stage ankle arthritis.
After investigating the numbers of ankle fusions and TARs performed in the previous year of the survey, the overall rates appear to be low, with the majority of surgeons reporting not having performed either procedure. Despite this survey being distributed to orthopedic surgeons specializing in primarily foot and ankle surgery, around half of surgeons reported that foot and ankle surgery represented <50% of their practice. This most probably reflects a low prevalence of patients with end-stage ankle arthritis, as well as the apparent low numbers of ankle fusions and TARs performed in the previous year of the survey. There appeared to be no obvious overall preference in relation to the number of ankle fusions or TARs that had been performed in the previous year. This perhaps is to be expected, as there has long been controversy among orthopedic surgeons with regard to which procedure provides the most favorable outcome for patients.1,7 The choice surgeons have to make when deciding whether to perform an ankle fusion or TAR is based on factors relating to the patient and surgeon performing the procedure. Improving patient selection as well as following clinical guidelines can help to achieve postoperative success.8,10
The survey showed that ankle fusions and TARs, on the whole, are being performed with relatively high levels of satisfaction. However, the results clearly show a preference for performing ankle fusions and higher levels of satisfaction when performing ankle and hindfoot fusions for patients with end-stage ankle arthritis. Specifically, ankle fusion was the preferred procedure by surgeons when managing patients with functional pain, post-traumatic arthritis, pantalar ankle arthritis, and ankle deformity. Pain is the primary indication for performing both an ankle fusion and TAR.2 Ankle fusion has good short-term results; however, in the long-term, patients often develop complications, such as progressive hindfoot and midfoot arthritis, as well as gait abnormalities.11
Survivorship of TARs has improved greatly over the last few decades, as demonstrated in the literature, but there is still some way to go before outcomes can be compared to other joint replacing procedures, such as total knee replacements.12 Reasons why a surgeon might choose to perform a fusion over a TAR are vast and include both patient and surgeon factors. As would be expected, complications become much less frequent with greater experience.12 One can assume that the amount of training and experience a surgeon has with performing TARs would influence both whether or not they would choose to perform this over an ankle fusion and their satisfaction with it. Not every patient is suitable for either a TAR or a fusion. The scenario, which presented the 55-year-old patient with functional pain, pantalar arthritis, and partially correctable varus deformity of 20°, received the most differing opinion with regard to whether the surgeon would perform a TAR (41%) or a fusion (47%). A limit of 10°–30° in either direction for performing a TAR has been suggested in the literature.13 This range of acceptability may account for the different suggestions of surgical management for this patient.
In patients with rheumatoid arthritis, TAR is generally preferred, as not only is its role to reduce pain, but it also aims to preserves joint function.6 As well as preserving function, TARs produce less stress on adjacent joints compared to fusions. The importance of this is to minimize the amount of stress posed on other joints in the lower limb, which may also be affected by rheumatoid arthritis. These benefits of joint preservation also come with the increased risks of implant failure, wound infections, and the possible need for revision surgery in the future.11 Our study shows clearly that for patients with rheumatoid arthritis, TAR in this scenario is the choice of management among foot and ankle surgeons in the Asia-Pacific region. It is worth highlighting that although the majority of surgeons would have performed a TAR, one-third of surgeons would have performed an ankle fusion for the patient with rheumatoid arthritis. This demonstrates that despite evidence in the literature supporting a TAR in this scenario, there remains some discrepancy in practice among surgeons in the Asia-Pacific region.
It is important to note the limitations of this study. This was a survey-based study, and as a result, it reflects the opinions of those included in the study and not necessarily actual clinical practice. As mentioned previously, many factors influence a surgeon’s choice to perform a particular procedure. Surgeons in our study were only presented with a very brief scenario on which to base their decision on. Some of the questions in the survey had lower response rates than others. In particular, there was a significantly low response rate from surgeons when asked about levels of satisfaction when performing a TAR (38%) in comparison to an open ankle fusion (86%), which meant there were less numbers to compare the two groups. This could have been due to a variation in the amount of experience with TARs surgeons included in the study had, so actual satisfaction levels when performing this procedure may not have been reflected accurately.
In conclusion, the prevalence of patients with end-stage ankle arthritis requiring surgery presenting to foot and ankle specialists in the region is low. Among specialists in the region, open ankle fusion remains the procedure of choice for the surgical management of end-stage ankle arthritis with the highest degree of surgeon comfort and satisfaction. Though infrequently performed, open ankle fusion, TAR, and arthroscopic ankle fusion are performed with a high degree of operator satisfaction in the minority of surgeons who do perform these procedures. Evidence in the modern literature for ankle fusions vs TAR is reflected by current practice trends in the Asia-Pacific region. The frequency of one surgical modality over another may be polarized by the prevalent patient subtype in this region.
APPENDIX 1
Questionnaire
End-stage Ankle Arthritis: A Survey of the Asia-Pacific Regional Foot and Ankle Surgeons
1. What proportion of your practice is foot and ankle surgery?
☐ 25% ☐ 50% ☐ 75% ☐ 100%
2. What is your usual source of referral for end-stage ankle arthritis?
☐ Self-referral.
☐ Orthopedic colleagues.
☐ General Practitioners.
☐ Other physicians in your hospital.
3. How many TARs have you performed in the last 1 year?
☐0 ☐1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ >5 ☐>10
4. What is your average operative time for a TAR (minutes)?
………………………………………………
5. When performing a primary TAR, which of the following associated procedures had you performed?
☐ None.
☐ Medial/lateral soft tissue plication/release.
☐ Calcaneal osteotomy/tibial osteotomy/malleolar
osteotomy.
6. How many ankle fusions have you performed in the last 1 year (including hindfoot fusions)?
☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ > 5 ☐ > 10 ☐ 10-20 ☐ 20-30 ☐ >30
7. On a visual analog scale of 0–10, please mark with an ‘X’ your level of satisfaction with performing the following procedures:
(a) TAR.
0 ----------------- 5 --------------------- 10
(b) Open ankle fusion.
0 ----------------- 5 ---------------------- 10
(c) Arthroscopic ankle fusion.
0 ------------------ 5 --------------------- 10
(d) Hindfoot fusion.
0 -------------------- 5 ------------------- 10
8. For the following case scenarios of end-stage ankle arthritis, please indicate your choice of surgical treatment:
(a) A 35-year-old male construction worker with functional pain and pantalar ankle arthritis but no deformity.
(b) A 45-year-old male with post-traumatic ankle arthritis, poor soft tissue envelope, and minimal deformity.
--------------------------------------------
(c) A 55-year-old female with functional pain, pantalar arthritis, and a varus deformity (partially correctable) of 20°.
--------------------------------------------
(d) A 65-year-old housewife with rheumatoid arthritis with ankle and subtalar arthritis with minimal deformity.
ORCID
Chin Yik Tan https://orcid.org/0000-0002-4154-9396
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