The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 10

Scientific Articles | October 01, 2007

Comparison of Reoperation Rates Following Ankle Arthrodesis and Total Ankle Arthroplasty

Nelson F. SooHoo, MD¹; David S. Zingmond, MD, PhD²; Clifford Y. Ko, MD, MS, MSHS³

¹ Department of Orthopaedic Surgery, University of California at Los Angeles, 10945 Le Conte Avenue, PVUB #3355, Los Angeles, CA 90095. E-mail address for N.F. SooHoo: nsoohoo@mednet.ucla.edu
² Department of General Internal Medicine and Health Services Research, University of California at Los Angeles School of Medicine, 911 Broxton Plaza, Los Angeles, CA 90095
³ Department of General Surgery, University of California at Los Angeles School of Medicine, 10833 Le Conte Avenue, CHS 72–215, Los Angeles, CA 90095

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site () and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Investigation performed at the Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, California

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J Bone Joint Surg Am, 2007 Oct 01;89(10):2143-2149. doi: 10.2106/JBJS.F.01611

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Abstract

Background: The role of ankle arthroplasty in the treatment of ankle arthritis is controversial. Ankle fusion is commonly performed, but there is ongoing concern about functional limitations and arthritis in the adjacent subtalar joint following ankle arthrodesis. The use of ankle arthroplasty as an alternative to ankle fusion is expanding, but reported results have been limited to those in case series. The purpose of this study was to compare the reoperation rates following ankle arthrodesis and ankle replacement on the basis of observational, population-based data from all inpatient admissions in California over a ten-year period. Our hypothesis was that patients treated with ankle replacement would have a lower risk of undergoing subtalar fusion but a higher overall risk of undergoing major revision surgery.

Methods: We used California's hospital discharge database to identify patients who had undergone ankle replacement or ankle arthrodesis as inpatients in the years 1995 through 2004. Short-term outcomes, including rates of major revision surgery, pulmonary embolism, amputation, and infection, were examined. Long-term outcomes that were analyzed included the rates of major revision surgery and subtalar joint fusion. Logistic and proportional hazard regression models were used to estimate the impact of the choice of ankle replacement or ankle fusion on the rates of adverse outcomes, with adjustment for patient factors including age and comorbidity.

Results: A total of 4705 ankle fusions and 480 ankle replacements were performed during the ten-year study period. Patients who had undergone ankle replacement had an increased risk of device-related infection and of having a major revision procedure. The rates of major revision surgery after ankle replacement were 9% at one year and 23% at five years compared with 5% and 11% following ankle arthrodesis. Patients treated with ankle arthrodesis had a higher rate of subtalar fusion at five years postoperatively (2.8%) than did those treated with ankle replacement (0.7%). Regression analysis confirmed a significant increase in the risk of major revision surgery (hazard ratio, 1.93 [95% confidence interval, 1.50 to 2.49]; p < 0.001) but a decreased risk of subtalar fusion (hazard ratio, 0.28 [95% confidence interval, 0.09 to 0.87]; p = 0.03) in patients treated with ankle replacement compared with those treated with ankle fusion.

Conclusions: This study confirms that, compared with ankle fusion, ankle replacement is associated with a higher risk of complications but also potential advantages in terms of a decreased risk of the patient requiring subtalar joint fusion. Additional controlled trials are needed to clarify the appropriate indications for ankle arthrodesis and ankle replacement.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

End-stage ankle arthritis is a debilitating condition that results in functional limitation and a poor quality of life^1-4. Arthrodesis has been the traditional treatment of ankle arthritis, but it may result in functional limitation due to loss of the range of motion of the ankle and an increased long-term risk of arthritis developing in adjacent hindfoot joints¹. Ankle arthroplasty has been advocated by some as an alternative to arthrodesis that may improve outcomes and diminish the risk of subtalar arthritis. The role of ankle arthroplasty in the surgical treatment of ankle arthritis remains controversial^2,5. The results of ankle arthroplasty have been evaluated in case series, with the authors of most of those studies having some relationship with implant manufacturers or designers^6,7. These studies showed promising results but did not include adequate control groups to allow direct comparison with ankle fusion. The case-series design also may result in bias in the selection of patients and publication of results. The purpose of this study was to use population-based data from a comprehensive database of inpatient admissions to compare the outcomes of ankle fusion and ankle replacement. The use of a large population-based dataset overcomes some of the biases inherent in the existing case series in the literature⁸.

In this observational study, we identified patients who had undergone ankle arthrodesis or ankle replacement as inpatients in California during the ten-year study period of 1995 through 2004. Rates of short-term and long-term complications requiring readmission, including major revision surgery, infection, pulmonary embolism, amputation, and subtalar fusion, were tracked. On the basis of the existing literature, we hypothesized that the risk of a reoperation was higher following primary total ankle replacement than it was following ankle arthrodesis^1,6,7. Conversely, we hypothesized that patients treated with ankle arthrodesis were more likely to require fusion of the adjacent subtalar joint¹.

Materials and Methods

Materials and Methods | Results | Discussion | Appendix | References

Data Source

Data on all hospital discharges in California in the years 1995 through 2004 were obtained from the patient discharge database compiled annually by California's Office of Statewide Health Planning and Development (OSHPD). This database includes discharge abstracts from all nonfederal hospitals in California. Each discharge abstract includes codes for up to twenty inpatient procedures and twenty-four diagnoses per hospitalization. All procedures and diagnoses are coded with use of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Also included are demographic information (race, Hispanic ethnicity, gender, expected source of payment, age, and ZIP code of residence), outcomes (in-hospital mortality), and site of hospitalization (a unique hospital identifier and ZIP code)⁹. Deaths were identified from the state death file¹⁰. Income was estimated by linkage to the median income reported by ZIP code in the 2000 United States Census. The study protocol was reviewed and approved by the UCLA (University of California at Los Angeles) institutional review board. Because of the nature of these secondary data analyses, the requirement for patient consent was waived.

Inclusion and Exclusion Criteria

The sample consisted of patients who had undergone their first primary total ankle replacement or ankle arthrodesis during the study period. The specific ICD-9-CM procedure codes used to identify the cohort sample are available in the Appendix. Patients with a non-California ZIP code were excluded. The unit of analysis was hospital discharge for each individual patient.

Outcomes Studied (Dependent Variables)

Both short-term and long-term outcomes were identified as dependent variables. The short-term outcomes of infection, pulmonary embolism, amputation, and a major revision procedure were analyzed for the first ninety days following the primary arthroplasty or fusion. A major revision procedure was defined by a code consistent with an inpatient readmission for any one or combination of the following procedures: revision arthroplasty, ankle arthroplasty, removal of a prosthesis, or ankle arthrodesis. Long-term outcomes followed throughout the study period included subtalar fusion and major revision procedures. These long-term outcomes are reported for patients at intervals of one year and five years after the primary procedure. The specific ICD-9-CM codes used to identify readmissions for short and long-term adverse outcomes are available in the Appendix.

Predictors (Independent Variables)

The main predictive variable of interest was the primary procedure—namely, ankle arthroplasty or ankle arthrodesis. Several additional patient characteristics were included in the regression models as covariates to adjust for their effect. These included age, gender, race/ethnicity, insurance type, proxy income assigned by ZIP code, and comorbid disease. Comorbid disease was assessed with use of the Charlson score and according to whether the patient had either complicated or uncomplicated diabetes or an underlying diagnosis of osteonecrosis, degenerative joint disease, or rheumatoid arthritis. The Charlson comorbidity index assesses seventeen comorbid conditions and has been validated for use in studies of administrative databases^11,12. Race and ethnicity are reported by the hospital, on the basis of the patient's self-report, and the median household income was assigned by proxy with use of data for each patient's ZIP code of residence.

Hospital surgical volume, defined as the average aggregate number of ankle fusion and ankle replacement procedures performed yearly during the study period, was also included as a covariate. Hospitals were categorized as low-volume if their annual volume was in the lowest 40th percentile among the annual volumes of hospitals in which ankle fusion and arthroplasty were performed. Intermediate-volume hospitals were defined as those in the next 40th percentile, and high-volume hospitals were defined as those in the highest 20th percentile.

Statistical Analysis

The patient sample is described with use of bivariate descriptive statistics. Results reported with use of descriptive statistics include patient demographics and annual rates of ankle fusion and ankle arthroplasty. Differences were determined with use of the t test for continuous variables and the Pearson chi-square test for categorical variables. Raw rates of complications are also reported separately for the arthrodesis and arthroplasty groups. Kaplan-Meier survival curves were used to generate a graphical comparison of unadjusted rates of long-term complications—i.e., subtalar fusion and major revision surgery—between patients treated with ankle arthrodesis and those treated with ankle arthroplasty.

We used multivariate regression techniques to identify the independent effect of the choice of surgery (arthrodesis or arthroplasty) on short-term and longer-term outcomes. For the analysis of the short-term outcomes (infection, pulmonary embolism, amputation, and a major revision procedure), in which the ninety-day follow-up was essentially complete for all patients in the cohort, we used multivariate logistic regression. We estimated the impact of the choice of primary procedure on each of these outcomes while accounting for patient demographics (age, gender, race/ethnicity, insurance type, and proxy income), comorbidities (Charlson comorbidity index, degenerative joint disease, rheumatoid arthritis, osteonecrosis, and diabetes), and provider characteristics (hospital volume). The strength of the association between the risk of short-term complications and the selection of a primary arthroplasty or arthrodesis is expressed as the odds ratios for a complication occurring in the ankle arthroplasty group with respect to the reference group of patients treated with ankle arthrodesis. Ninety-five percent confidence intervals and p values are reported as well.

For the assessment of longer-term complications, in which definition of a specific follow-up time would have excluded a large number of patients from the analysis, we used a time-to-event analysis with Cox proportional hazard regression models. We performed separate analyses of the independent impact of the choice of primary procedure (arthrodesis or arthroplasty) on long-term outcomes (subtalar fusion and a major revision procedure) using the same covariates as were used for the logistic regression models. The strength of the association between the risk of long-term complications and the selection of primary arthroplasty or arthrodesis is expressed as the adjusted hazard ratio (where the "hazard" is defined as the probability of the outcome occurring in a unit period of time) for complications occurring in the ankle arthroplasty group with respect to the reference group of patients treated with ankle arthrodesis. Ninety-five percent confidence intervals and p values are reported as well.

Results

Materials and Methods | Results | Discussion | Appendix | References

Patient Sample

A total of 4705 patients underwent ankle arthrodesis and 480 underwent ankle arthroplasty during the ten-year study period. Table I shows the annual incidence of each procedure. The number of arthroplasties rose in 1999. Table II lists demographic information for the patients receiving each operation. There was a significant difference in the mean age of the patients treated with ankle replacement (fifty-nine years) compared with that in the ankle fusion group (fifty-five years) (p < 0.001). Despite a younger mean age, the patients treated with ankle fusion had a significantly higher rate of complicated diabetes (p < 0.001) than did the patients treated with ankle replacement. Also, a higher percentage of patients treated with ankle fusion were of black race or Hispanic ethnicity (p = 0.001). The patients treated with ankle replacement had a higher median income (p < 0.001) and were less likely to have safety-net health insurance as represented by Medicaid (p < 0.001). Rheumatoid arthritis was more common in the ankle replacement group (p < 0.001), whereas osteonecrosis was more prevalent in the fusion group (p = 0.01).

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TABLE I Ankle Fusion and Ankle Replacement in California from 1995 Through 2004

	No. of Cases
Year	Ankle Fusion	Ankle Replacement
1995	527	25
1996	543	19
1997	442	16
1998	445	18
1999	414	56
2000	428	70
2001	445	65
2002	426	76
2003	517	78
2004	518	57
Total	4705	480

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TABLE I Ankle Fusion and Ankle Replacement in California from 1995 Through 2004

	No. of Cases
Year	Ankle Fusion	Ankle Replacement
1995	527	25
1996	543	19
1997	442	16
1998	445	18
1999	414	56
2000	428	70
2001	445	65
2002	426	76
2003	517	78
2004	518	57
Total	4705	480

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TABLE II Demographics of Patient Sample

	Ankle Fusion	Ankle Replacement	P Value
Mean age (range) (yr)	55 (18-95)	59 (19-88)	<0.001
M/F (%)	52/48	49/51	0.17
White race (%)	78	84	0.001
Medicaid recipients (%)	8	3	<0.001
Median income ($)	56,979	64,973	<0.001
Mean Charlson comorbidity index and stand. dev.	0.56 ± 1.06	0.53 ± 0.97	0.52
Degenerative joint disease (%)	48.29	57.50	<0.001
Rheumatoid arthritis (%)	6.08	10.42	<0.001
Osteonecrosis (%)	2.81	0.83	0.01
Uncomplicated diabetes (%)	6.63	5.83	0.50
Complicated diabetes (%)	3.91	0.00	<0.001

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TABLE II Demographics of Patient Sample

	Ankle Fusion	Ankle Replacement	P Value
Mean age (range) (yr)	55 (18-95)	59 (19-88)	<0.001
M/F (%)	52/48	49/51	0.17
White race (%)	78	84	0.001
Medicaid recipients (%)	8	3	<0.001
Median income ($)	56,979	64,973	<0.001
Mean Charlson comorbidity index and stand. dev.	0.56 ± 1.06	0.53 ± 0.97	0.52
Degenerative joint disease (%)	48.29	57.50	<0.001
Rheumatoid arthritis (%)	6.08	10.42	<0.001
Osteonecrosis (%)	2.81	0.83	0.01
Uncomplicated diabetes (%)	6.63	5.83	0.50
Complicated diabetes (%)	3.91	0.00	<0.001

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Fig. 1: Kaplan-Meier survival curve for ankle fusion and ankle replacement with subtalar fusion as the end point.

Short-Term Complications

The raw incidences of short-term complications are shown in the Appendix. Table III shows the odds ratios, along with 95% confidence intervals and p values, of short-term complications occurring in patients treated with ankle replacement relative to the occurrence in patients treated with ankle fusion. At ninety days postoperatively, patients treated with ankle arthroplasty had an increased rate of major revision, with a significant increase in the odds ratio to 3.65 (95% confidence interval, 1.30 to 10.29, p = 0.01). There was no significant difference in the overall rate of readmissions for infectious complications, but the patients treated with ankle replacement had a higher risk of readmission for infection related to an implanted device. The infrequent complications of below-the-knee amputation (0.3%), acute osteomyelitis (0.4%), and chronic osteomyelitis (0.1%) occurred only in the ankle fusion group.

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TABLE III Odds Ratios of Short-Term Complications and Hazard Ratios of Long-Term Complications Occurring in the Ankle Replacement Group in Comparison with the Ankle Fusion Group

	Odds/Hazard Ratio (95% Confidence Interval)	P Value
Short-term complication (at 90 days)
Pulmonary embolism	0.65 (0.81-5.19)	0.68
Infection
Total	1.58 (0.85-2.92)	0.15
Postoperative	1.21 (0.56-2.61)	0.63
Device-related	2.68 (1.12-6.43)	0.03^*
Major revision procedure	3.65 (1.30-10.29)	0.01^*
Long-term complication
Subtalar fusion	0.28 (0.09-0.87)	0.03^*
Triple arthrodesis	0.68 (0.24-1.91)	0.46
Tarsometatarsal fusion	1.13 (0.13-10.09)	0.91
Major revision procedure	1.93 (1.50-2.49)	<0.001^*

The p value was significant (p < 0.05).

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TABLE III Odds Ratios of Short-Term Complications and Hazard Ratios of Long-Term Complications Occurring in the Ankle Replacement Group in Comparison with the Ankle Fusion Group

	Odds/Hazard Ratio (95% Confidence Interval)	P Value
Short-term complication (at 90 days)
Pulmonary embolism	0.65 (0.81-5.19)	0.68
Infection
Total	1.58 (0.85-2.92)	0.15
Postoperative	1.21 (0.56-2.61)	0.63
Device-related	2.68 (1.12-6.43)	0.03^*
Major revision procedure	3.65 (1.30-10.29)	0.01^*
Long-term complication
Subtalar fusion	0.28 (0.09-0.87)	0.03^*
Triple arthrodesis	0.68 (0.24-1.91)	0.46
Tarsometatarsal fusion	1.13 (0.13-10.09)	0.91
Major revision procedure	1.93 (1.50-2.49)	<0.001^*

The p value was significant (p < 0.05).

Long-Term Complications

The incidences of long-term complications associated with ankle replacement and ankle fusion are shown in the Appendix, and the hazard ratios reflecting the risk of complications in the patients treated with ankle replacement relative to the risk in the reference group of patients treated with ankle arthroplasty are shown in Table III. The raw rates of subtalar fusion at five years postoperatively were 2.8% in the ankle fusion group and 0.7% in the arthroplasty group, with a significantly lower risk of subtalar fusion being required in patients treated with ankle replacement than in those treated with ankle fusion (hazard ratio, 0.28 [95% confidence interval, 0.09 to 0.87]; p = 0.03). There was no significant difference in the risk of triple arthrodesis or tarsometatarsal fusion between the two groups. Midtarsal fusion was a rare occurrence, with only eight cases, all in the ankle fusion group.

Overall, 23% of the patients who had been treated with an arthroplasty underwent a major revision procedure by five years postoperatively compared with 11% of the patients who had been treated with a fusion. Cox regression analysis identified a higher risk of a major revision, with a hazard ratio of 1.93 (95% confidence interval, 1.50 to 2.49; p < 0.001), for the ankle arthroplasty group relative to the fusion group. Kaplan-Meier survival curves are provided to illustrate the long-term outcomes of ankle fusions and arthroplasties—i.e., the rates of subtalar fusion (Fig. 1) and major revision (Fig. 2).

Discussion

Materials and Methods | Results | Discussion | Appendix | References

Substantial debate remains regarding the role of ankle replacement in the treatment of ankle arthritis. Ankle fusion has been shown to have successful results, but there is ongoing concern regarding the long-term consequences in terms of both functional limitation and arthritis of the adjacent subtalar joint¹. Previous studies of both ankle arthrodesis and ankle replacement have consisted of case series from single institutions, with the studies of arthroplasty often supported by implant makers⁶. In the present study, we overcame some of the limitations of case series by using population-based data⁸. Our results confirm a higher risk of subtalar fusion on long-term follow-up after ankle arthrodesis when compared with the risk following ankle replacement. However, patients treated with ankle replacement were at high risk for a reoperation and some infection-related complications.

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Fig. 2: Kaplan-Meier survival curve for ankle fusion and ankle replacement with major revision surgery as the end point.

This study provides a population-based comparison of the outcomes following ankle arthrodesis and ankle replacement. The rates of adverse outcomes in our study were similar to those seen in the published literature^1,2,6. The rate of major revision surgery at five years following ankle replacement was 23% compared with 11% in the arthrodesis group. These reoperations included ankle arthroplasty, revision ankle arthroplasty, implant removal, conversion to an ankle fusion, or any combination of those procedures. A previous study indicated that the cost-effectiveness of ankle replacement depends on an implant survival of ten years or longer⁵. The present study demonstrated that a large percentage of ankle prostheses are not likely to survive for this period of time. These findings suggest that additional controlled trials comparing arthrodesis and arthroplasty are needed to clarify the appropriate indications for each procedure.

We also analyzed the role of covariates such as age, gender, race/ethnicity, comorbidity, and underlying diagnosis in predicting outcomes following ankle replacement and ankle fusion. Both comorbidity and the underlying diagnosis are independent predictors of outcome. Specifically, patients with diabetes, rheumatoid arthritis, or osteonecrosis had a higher odds ratio for infection on short-term follow-up and a higher hazard ratio for revision during the ten-year study period. In our sample, the patients treated with ankle fusion were more likely to have complicated diabetes. In addition, they had a lower median income, a higher proportion had safety-net insurance, and they were more likely to be black or Hispanic. Rheumatoid arthritis was more common in the replacement group, whereas osteonecrosis was more common in the fusion group. The distribution of these patient factors should be considered when evaluating the results of case series^13-16.

The major weakness of this study is that the population of patients who underwent ankle arthroplasty may not be comparable with the one that underwent ankle arthrodesis. The indications for ankle replacement differ substantially from those for arthrodesis, and direct comparison of both the demographics and outcomes of these procedures may not be appropriate. Specifically, it is likely that comorbidities such as ankle instability, bone loss, and deformity were more common in the ankle arthrodesis group. Our study was unable to account for these differences between the patient populations, and our results may underestimate the increase in the rates of complications of arthroplasty relative to those associated with arthrodesis. In addition, subtalar arthritis is a potential contraindication for ankle arthroplasty. This may account for the higher rate of subtalar fusion in the arthrodesis group and may have resulted in an overestimation in our study of the contribution of ankle fusion to subtalar pathology. A randomized, controlled trial would be helpful to more accurately determine the difference in complication rates between arthrodesis and arthroplasty in patients with preoperative arthritis and deformity of comparable severity.

An additional weakness of this study is the limited types of data available in administrative databases. Data on functional outcomes are not available. Further study is required to identify differences in the functional outcomes of these two procedures. In addition, ankle fusion and arthroplasty procedures performed on an outpatient basis are not captured in the databases that we analyzed. Similarly, rates of complications not requiring readmission, such as superficial infections and minor pulmonary emboli, were not available for analysis. The reoperation rate may also be understated, as only those procedures requiring readmission were included in our analysis. Minor procedures, such as hardware removal, performed on an outpatient basis were not included in our study. Despite these limitations, we have provided useful comparative data on several important short and long-term outcomes of ankle replacement and ankle fusion. These include rates of infection, amputation, pulmonary embolism, major revision procedures, and subtalar fusion.

In this study, we compared, for what we believe was the first time, population-based rates of complications following ankle replacement and ankle fusion. Ankle replacement was shown to be associated with a higher rate of major revision surgery (23% at five years postoperatively). Conversely, we confirmed that patients treated with ankle arthrodesis have a higher risk of requiring subtalar fusion over the long term than do patients who have undergone ankle replacement, although the rate at five years remained relatively low (2.8%). These findings support the rationale that ankle fusion increases the risk of adjacent subtalar arthritis and that there may be benefits of continued efforts to improve the survival of ankle implants. However, given the high rate of major surgical revisions, controlled trials would be helpful to clarify the optimal indications for total ankle arthroplasty.

Appendix

Materials and Methods | Results | Discussion | Appendix | References

The specific procedure codes used to identify the cohort sample and tables showing details of the complications are available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on "Supplementary Material") and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM). ?

References

Materials and Methods | Results | Discussion | Appendix | References

Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001;83: 219-28.83219 2001 [PubMed]

Saltzman C. Editorial: Why ankle replacement? Clin Orthop Relat Res. 2004: 424: 2.4242 2004 [PubMed][CrossRef]

Saltzman CL, Salamon ML, Blanchard GM, Huff T, Hayes A, Buckwalter JA, Amendola A. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25: 44-6.2544 2005 [PubMed]

Saltzman CL, Zimmerman MB, O'Rourke M, Brown TD, Buckwalter JA, Johnston R. Impact of comorbidities on the measurement of health in patients with ankle osteoarthritis. J Bone Joint Surg Am. 2006;88: 2366-72.882366 2006 [CrossRef]

SooHoo NF, Kominski G. Cost-effectiveness analysis of total ankle arthroplasty. J Bone Joint Surg Am. 2004;86: 2446-55.862446 2004

Easley ME, Vertullo CJ, Urban WC, Nunley JA. Total ankle arthroplasty. J Am Acad Orthop Surg. 2002;10: 157-67.10157 2002 [PubMed]

Knecht SI, Estin M, Callaghan JJ, Zimmerman MB, Alliman KJ, Alvine FG, Saltzman CL. The Agility total ankle arthroplasty. Seven to sixteen-year follow-up. J Bone Joint Surg Am. 2004;86: 1161-71.861161 2004

Gallin JI. Principles and practice of clinical research. San Diego: Academic Press; 2002. 2002

SooHoo NF, Lieberman JR, Ko CY, Zingmond DS. Factors predicting complication rates following total knee replacement. J Bone Joint Surg Am. 2006;88: 480-5.88480 2006 [PubMed][CrossRef]

Zingmond DS, Ye Z, Ettner SL, Liu H. Linking hospital discharge and death records—accuracy and sources of bias. J Clin Epidemiol. 2004;57: 21-9.5721 2004 [PubMed][CrossRef]

Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45: 613-9.45613 1992 [PubMed][CrossRef]

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Liu JH, Zingmond DS, McGory ML, SooHoo NF, Ettner SL, Brook RH, Ko CY. Disparities in the utilization of high-volume hospitals for complex surgery. JAMA. 2006;296: 1973-80.2961973 2006 [PubMed][CrossRef]

Skinner J, Weinstein JN, Sporere SM, Wennberg JE. Racial, ethnic, and geographic disparities in rates of knee arthroplasty among Medicare patients. N Engl J Med. 2003;349: 1350-9.3491350 2003 [PubMed][CrossRef]

Skinner J, Zhou W, Weinstein J. The influence of income and race on total knee arthroplasty in the United States. J Bone Joint Surg Am. 2006; 88: 2159-66.882159 2006 [PubMed][CrossRef]

Topics

repeat surgery ; infection ; arthroplasty ; ankle arthrodesis ; ankle replacement arthroplasty ; subtalar joint arthrodesis

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Nelson F. SooHoo, David S. Zingmond, Clifford Y. Ko; Comparison of Reoperation Rates Following Ankle Arthrodesis and Total Ankle Arthroplasty. The Journal of Bone & Joint Surgery. 2007 Oct;89(10):2143-2149.

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