Introduction. Despite the increasing numbers of ankle replacements that are being performed there are still limited studies on the survival of ankle replacements and comparisons between different implants. The primary aim of this study is to link NJR data with NHS digital data to determine the true failure rates of ankle replacements. Secondary outcomes include analysis risk factors for failure, patient demographics and outcomes of individual prosthesis. Methods. A data linkage study combined National Joint Registry Data and NHS Digital data. The primary outcome of failure is defined as the removal or exchange of any components of the implanted device inserted during ankle replacement surgery. Life tables and Kaplan Meier survival charts demonstrated survivorship. Cox proportional hazards regression models with the Breslow method used for ties were fitted to compare failure rates. Results. 5,562 primary ankle replacement were recorded on the NJR. The 1-year survivorship was 98.8% (95% CI 98.4%–99.0%), 5-year survival in 2725 patients was 90.2% (95% CI 89.2%–91.1%), and 10-year survival in 199 patients was 86.2% (95% CI 84.6%–87.6%). When using a Cox regression model for all implants with over 100 implantations using the Infinity as the reference, only the Star (Hazard ratio 1.60 95% CI 0.87–2.96) and Inbone (HR 0.38 95% CI 0.05–2.84) did not produce significantly worse survivorship. Conclusion. Ankle replacements have increased in numbers over the past decade, and the currently used implants have lower failure rates than older prosthesis. It is expected that in the future the outcomes of ankle replacements will continue to improve

The National Joint Registry (NJR) was established in 2003, and was extended to include ankle arthroplasty on 1. st. April 2010, and shoulder and elbow arthroplasty in April 2012. The aim of this study was to evaluate the uptake of the NJR for ankle arthroplasty over its first 3 years. This is compared to the first 3 years of hip and knee data, and the first year of shoulder and elbow data. The methods of measuring compliance are also evaluated. NJR compliance is measured by comparing the number of procedures submitted to the NJR, against the number of levies raised through implant sales. This applies to all of the UK, and both independent and NHS providers. However, compliance can also be measured by comparing NJR submissions with data submitted to the Hospital Episode Statistics (HES) database. This only relates to NHS institutions in England. The NJR ankle data was compared to implant data, and adjusted to compare to HES data, to evaluate the different methods of measuring compliance. We also compared these figures with the first 3 years for hip and knee arthroplasties and the first year for shoulder and elbow arthroplasties. Results:. In 2011 there were 493 arthroplasties and the compliance was 64% against industry data. In 2012 there were 590 procedures with compliance improved to 77% against industry data. When adjusting NJR to compare with HES data, the compliance was 87% in 2012., with 507 ankle arthroplasties registered with the NJR and 582 on HES data. The reasons for this discrepancy are discussed. The specific difficulties of capturing ankle revisions are discussed, as some get revised to arthrodeses. The uptake is significantly higher than the first year for all other joints (shoulders 52%, hips 57%, knees 57%, and elbows 60%)

Aims. Despite the increasing numbers of ankle arthroplasties, there are limited studies on their survival and comparisons between different implants. The primary aim of this study was to determine the failure rates of primary ankle arthroplasties commonly used in the UK. Methods. A data linkage study combined National Joint Registry (NJR) data and NHS Digital data. The primary outcome of failure was defined as the removal or exchange of any components of the implanted device. Life tables and Kaplan-Meier survival charts were used to illustrate survivorship. Cox proportional hazards regression models were fitted to compare failure rates between 1 April 2010 and 31 December 2018. Results. Overall, 5,562 primary ankle arthroplasties were recorded in the NJR. Linked data show a one-year survivorship of 98.8% (95% confidence interval (CI) 98.4% to 99.0%), five-year survival in 2,725 patients of 90.2% (95% CI 89.2% to 91.1%), and ten-year survival in 199 patients of 86.2% (95% CI 84.6% to 87.6%). The five-year survival for fixed-bearing implants was 94.3% (95% CI 91.3% to 96.3%) compared to 89.4% (95% CI 88.3% to 90.4%) for mobile-bearing implants. A Cox regression model for all implants with over 100 implantations using the implant with the best survivorship (Infinity) as the reference, only the STAR (hazard ratio (HR) 1.60 (95% CI 0.87 to 2.96)) and INBONE (HR 0.38 (95% CI 0.05 to 2.84)) did not demonstrate worse survival at three and five years. Conclusion. Ankle arthroplasties in the UK have a five-year survival rate of 90.2%, which is lower than recorded on the NJR, because we have shown that approximately one-third of ankle arthroplasty failures are not reported to the NJR. There are statistically significant differences in survival between different implants. Fixed-bearing implants appear to demonstrate higher survivorship than mobile-bearing implants. Cite this article: Bone Joint J 2023;105-B(3):301–306

Aims. When a total ankle arthroplasty (TAA) fails, it can be converted to a fusion or a revision arthroplasty. Despite the increasing numbers of TAAs being undertaken, there is little information in the literature about the management of patients undergoing fusion following a failed TAA. The primary aim of this study was to analyze the survival of fusions following a failed TAA using a large dataset from the National Joint Registry (NJR). Methods. A data linkage study combined NJR and NHS Digital data. Failure of a TAA was defined as a fusion, revision to a further TAA, or amputation. Life tables and Kaplan-Meier graphs were used to record survival. Cox proportional hazards regression models were fitted to compare the rates of failure. Results. A total of 131 patients underwent fusion as a salvage procedure following TAA. Their mean age was 65.7 years (SD 10.6) and 73 (55.7%) were male. The mean follow-up was 47.5 months (SD 27.2). The mean time between TAA and fusion was 5.3 years (SD 2.7). Overall, 32 (24.4%) underwent reoperations other than revision and 29 (22.1%) failed. Of these 24 (18.3%) underwent revision of the fusion and five (3.8%) had a below-knee amputation. No patients underwent conversion to a further TAA. Failure usually occurred in the first three postoperative years with one-year survival of fusion being 96.0% (95% confidence interval (CI) 90.7 to 98.3) and three-year survival in 69 patients being 77.5% (95% CI 68.3 to 84.4). Conclusion. Salvage fusion after a failed TAA shows moderate rates of failure and reoperations. Nearly 25% of patients required revision within three years. This study is an extension of studies using the same methodology reporting the failure rates and risk factors for failure, which have recently been published, and also one reporting the outcome of revision TAA for a failed primary TAA, using the same methodology, which will shortly be published. Cite this article: Bone Joint J 2023;105-B(10):1094–1098

Aims. The number of revision total ankle arthroplasties (TAAs) which are undertaken is increasing. Few studies have reported the survival after this procedure. The primary aim of this study was to analyze the survival of revision ankle arthroplasties using large datasets. Secondary aims were to summarize the demographics of the patients, the indications for revision TAA, further operations, and predictors of survival. Methods. The study combined data from the National Joint Registry and NHS Digital to report the survival of revision TAA. We have previously reported the failure rates and risk factors for failure after TAA, and the outcome of fusion after a failed TAA, using the same methodology. Survival was assessed using life tables and Kaplan Meier graphs. Cox proportional hazards regression models were fitted to compare failure rates. Results. A total of 228 patients underwent revision TAA. The mean follow-up was 2.6 years (SD 2.0). The mean time between the initial procedure and revision was 2.3 years (SD 1.8). The most commonly used implant was the Inbone which was used in 81 patients. A total of 29 (12.7%) failed; nine (3.9%) patients underwent a further revision, 19 (8.3%) underwent a fusion, and one (0.4%) had an amputation. The rate of survival was 95.4% (95% confidence interval (CI) 91.6 to 97.5) at one year, 87.7% (95% CI 81.9 to 91.7; n = 124) at three years and 77.5% (95% CI 66.9 to 85.0; n = 57) at five years. Revision-specific implants had a better survival than when primary implants were used at revision. A total of 50 patients (21.9%) had further surgery; 19 (8.3%) underwent reoperation in the first 12 months. Cox regression models were prepared. In crude analysis the only significant risk factors for failure were the use of cement (hazard ratio (HR) 3.02 (95% CI 1.13 to 8.09)) and the time since the primary procedure (HR 0.67 (95% CI 0.47 to 0.97)). No risk factors for failure were identified in multivariable Cox regression modelling. Conclusion. Revision TAAs have good medium term survival and low rates of further surgery. New modular revision implants appear to have improved the survival compared with the use of traditional primary implants at revision. Cite this article: Bone Joint J 2023;105-B(11):1184–1188

Introduction. This is a multi-centre, prospective, observational study of 503 INFINITY fixed bearing total ankle arthroplasties. We report the minimum two-year results of this prosthesis which was introduced to the UK Market in 2014 and is now the most used ankle arthroplasty in the National Joint Registry of England and Wales. Methods. Patients were recruited from 11 centres in the United Kingdom between June 2016 and November 2019. Demographic, radiographic, and functional outcome data (Ankle Osteoarthritis Scale, Manchester Oxford Foot Ankle Questionnaire and Euroquol 5D-5L) were collected preoperatively, at 6 months, 1 year and 2 years and 5 years. The average age was 67.8 (range 23.9 to 88.5) and average BMI 29.3 (18.9 to 48.0). The COFAS grading system was used to stratify deformity. There were 261 (51.9%) COFAS Type 1, 122 (24.2%) COFAS Type 2, 31 (6.2%) COFAS 3 and 89 (17.7%) COFAS type 4. 38 patients (7.6%) presented with inflammatory arthritis. 99 (19.7%) implantations utilised patient specific instrumentation. Complications and reoperations were recorded as adverse events. Radiographs were assessed for lucencies, cysts and/or subsidence. Results. The mean follow up was 34.2 months (range 24–64). 15 patients have died, 8 withdrawn and 3 lost to follow up. 8 implants (1.6%) have been revised. According to the Glazebrook classification there were low grade complications in 6.6%, medium grade in 1.4% and high grade in 1.6%. There have been an additional 13 non revision re-operations (2.6%) at the latest follow up. There was a significant (p < 0.01) improvement across all functional outcome scores at a minimum of 2yr follow up. Discussion and conclusion. This large cohort has shown a low early revision rate and high functional outcomes with a low-profile fixed bearing prosthesis

Aims. The aim of this study was to capture 12-month outcomes from a representative multicentre cohort of patients undergoing total ankle arthroplasty (TAA), describe the pattern of patient-reported outcome measures (PROMs) at 12 months, and identify predictors of these outcome measures. Methods. Patients listed for a primary TAA at 19 NHS hospitals between February 2016 and October 2017 were eligible. PROMs data were collected preoperatively and at six and 12 months including: Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ (foot and ankle)) and the EuroQol five-dimension five-level questionnaire (EQ-5D-5L). Radiological pre- and postoperative data included Kellgren-Lawrence score and implant position measurement. This was supplemented by data from the National Joint Registry through record linkage to determine: American Society of Anesthesiologists (ASA) grade at index procedure; indication for surgery, index ankle previous fracture; tibial hind foot alignment; additional surgery at the time of TAA; and implant type. Multivariate regression models assessed outcomes, and the relationship between MOXFQ and EQ-5D-5L outcomes, with patient characteristics. Results. Data from 238 patients were analyzed. There were significant improvements in MOXFQ and EQ-5D-5L among people who underwent TAA at six- and 12-month assessments compared with preoperative scores (p < 0.001). Most improvement occurred between preoperative and six months, with little further improvement at 12 months. A greater improvement in MOXFQ outcome postoperatively was associated with older age and more advanced radiological signs of ankle osteoarthritis at baseline. Conclusion. TAA significantly benefits patients with end-stage ankle disease. The lack of substantial further overall change between six and 12 months suggests that capturing PROMs at six months is sufficient to assess the success of the procedure. Older patients and those with advanced radiological disease had the greater gains. These outcome predictors can be used to counsel younger patients and those with earlier ankle disease on the expectations of TAA. Cite this article: Bone Joint J 2023;105-B(8):895–904

Aims. We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre. Methods. Between December 2010 and May 2016, 118 consecutive Zenith prostheses were implanted in 114 patients. Demographic, clinical, and patient-reported outcome measures (PROMs) data were collected. The endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan-Meier survival curves were generated with 95% confidence intervals (CIs) and the rate of failure calculated for each year. Results. Eight patients (ten ankles) died during follow-up, but none required revision. Of the surviving 106 patients (108 ankles: rheumatoid arthritis (RA), n = 15; osteoarthritis (OA), n = 93), 38 were women and 68 were men, with a mean age of 68.2 years (48 to 86) at the time of surgery. Mean follow-up was 5.1 years (2.1 to 9.0). A total of ten implants failed (8.5%), thus requiring revision. The implant survival at seven years, using revision as an endpoint, was 88.2% (95% CI 100% to 72.9%). There was a mean improvement in Manchester-Oxford Foot and Ankle Questionnaire (MOXFQ) from 85.0 to 32.8 and visual analogue scale (VAS) scores from 7.0 to 3.2, and overall satisfaction was 89%. The three commonest complications were malleolar fracture (14.4%, n = 17), wound healing (13.6%, n = 16), and superficial infection (12.7%, n = 15). The commonest reason for revision was aseptic loosening. No patients in our study were revised for deep infection. Conclusion. Our results show that Zenith survival rates are comparable with those in the literature for other implants and in the National Joint Registry (NJR). Overall patient satisfaction was high as were functional outcomes. However, the data highlight potential complications associated with this surgery. The authors believe that these figures support ankle arthroplasty as an option in the treatment of ankle arthritis. Cite this article: Bone Joint J 2021;103-B(4):696–703

The effect of BMI on patient-reported outcomes following total ankle replacement (TAR) is uncertain and the change in BMI experienced by these patients in the 5 years following surgery has not been studied. We report a series of 106 patients with complete 5-year data on BMI and patient-reported outcome scores. Patients undergoing TAR between 2006 and 2009, took part in the hospital joint registry, which provides routine clinical audit of patient progress following total joint arthroplasty; therefore, ethics committee approval was not required for this study. Data on BMI, Foot and Ankle Score (FAOS) and SF-36 score were collected preoperatively and annually postoperatively. Patients who were obese (BMI >30) had lower FAOS scores pre-operatively and at 5 years, however this did not reach significance. Both obese (p = 0.0004) and non-obese (p < 0.0001) patients demonstrated a significant improvement in FAOS score from baseline to 5 years. This improvement was more marked for the non-obese patients. No significant differences were seen for SF36 scores between obese and non-obese patients either at baseline or 5 years. There was a trend for improved score in both groups. Mean pre-operative BMI was 28.49. Mean post-operative BMI was 28.33. The mean difference between pre- and post-operative BMI was −0.15, which was not statistically significant (p=0.55). There were no significant differences in revisions in the obese (2) and non-obese (1 and one awaited) groups at 5 years. This data supports use of TAR in the obese population, as significant increases in mean FAOS score were seen in this group at 5 years. Obesity did not have a significant influence on patients' overall health perceptions, measured by the SF36 and a trend for improvement was seen in both obese and non-obese patients. TAR cannot be relied upon to result in significant post-operative weight-loss without further interventions

Introduction. Traditional treatment for end-stage ankle arthritis has been ankle arthrodesis, however ankle arthroplasty is becoming an accepted alternative. The Zenith Ankle (Corin, UK) is 3rd generation implant with a mobile bearing design. In the NJR 2016 report, the Zenith was the commonest ankle prosthesis implanted in the UK. However, compared to other ankle implants, there's little published data on its performance and survival. The aim of this study was to analyse outcome in a consecutive series from a non-designer centre. Method. We conducted a retrospective review of a consecutive series of 118 Zenith Ankle replacements implanted in our Unit (December 2010 to May 2016). Data was collected from our National Joint Registry entries, research databases, patient notes, PACS and PROMS. Results. Average age was 68.2 years (range 46–46 years; 75M:43F; 97 Osteoarthritis, 20 inflammatory arthritis, 1 haemophilia). Results show a 95.8% survivorship at average 3.5 years follow up (range 0.6–6.3 years). 5 patients (4.2%) required revision. Average pre- and post-op MOXFQ scores were 85.0/100 and 32/100 respectively with improvements in VAS from 7.0/10 to 3.6/10, with an average range of movement of 20.4 degrees. Overall satisfaction rate was 89%. There were 65 complications in 55 patients, but only 7.7% of these led to detrimental effects on the implant. The commonest were malleolar fracture (14.4%), wound problems (13.6%) and superficial infection (12.7%), medial gutter pain (10.2%). There were no cases of deep infection. Five patients required revision (all were revised to revision arthroplasty), for component loosening, or pain and stiffness. Conclusions. This is largest non-designer centre series examining the outcomes of the Zenith implant. Survival figures for this implant are comparable to NJR averages (6.8% revision at 5 years), with high levels of patient functional outcome and satisfaction. The data highlights the risks associated with this procedure

Aims

This study reports updates the previously published two-year clinical, functional, and radiological results of a group of patients who underwent transfibular total ankle arthroplasty (TAA), with follow-up extended to a minimum of five years.

Introduction:. The National Joint Registry has been capturing data on ankle replacement surgery since April 2010. This currently represents the largest cohort of ankles replacements captured worldwide and is a valuable resource to give us short term outcome of ankle replacement surgery. Methods:. All the ankle replacements on the NJR were linked to the HES database using deterministic methods. The results were then anonymised. We then looked at Hopital admissions after the ankle replacement had taken place. Results:. There were just over 1600 ankles on the NJR and linking to HES gave 2065 records. 1437 of these were relevant to TAR. There were 12 malleolar fractures post-op and 6 DVT/PE which required readmission. there were 49 reoperations other than revision, 12 of which were ankle arthroscopies, and 14 removal of metalwork. Conclusion:. Ankle replacement is a effective procedure but does carry with it the risk of short term reoperation

Introduction:. The aim of this study was to assess patients reported fitness to return to work and to driving after ankle replacement. Method:. Using Hospital Joint Registry, patients who underwent ankle replacement between 2006 and 2011 were invited to take part in the study. Questionnaires were sent to these patients. Participants were asked to report the nature and pattern of their work (full time or part time), time it took to return to work and subsequent nature of work. Participants were also asked about time to return to driving. Results:. 173 participants were given eight weeks to reply. In this time there were 131 responses (response rate 76%). There were 79 male and 52 female respondents. Of the responses 61% (n=80) were retired, 24% (n=42) were employed, 5% (n=9) were unemployed before the surgery. Of those who were employed prior to ankle replacement, 29 respondents reported working full time and 11 respondents were working part time and 5 were self employed. 10 (24%) patients returned to work at 6 weeks 22 (52%) were able to work by 3 months. Following surgery 5 of the patients did not return to work off which one took retirement. 45 (40%) respondents could drive at 6 weeks, 34 (22%) at 3 months and 11 by 6 months. 20 (12%) patients did not drive before surgery. There were 23 responses about nature of employment, 10 being manual workers and 13 being office workers. Of the manual workers 5 patients returned to full time work. Conclusion:. We conclude from this study that the 76% of the employed patients prior to their ankle replacement were able to return to work by 6 months with 24 % returning by 6 weeks. 71% were able to drive at 3 months after surgery

Aims

We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.

We performed a systematic review and meta-analysis of modern total ankle replacements (TARs) to determine the survivorship, outcome, complications, radiological findings and range of movement, in patients with end-stage osteoarthritis (OA) of the ankle who undergo this procedure. We used the methodology of the Cochrane Collaboration, which uses risk of bias profiling to assess the quality of papers in favour of a domain-based approach. Continuous outcome scores were pooled across studies using the generic inverse variance method and the random-effects model was used to incorporate clinical and methodological heterogeneity. We included 58 papers (7942 TARs) with an interobserver reliability (Kappa) for selection, performance, attrition, detection and reporting bias of between 0.83 and 0.98. The overall survivorship was 89% at ten years with an annual failure rate of 1.2% (95% confidence interval (CI) 0.7 to 1.6). The mean American Orthopaedic Foot and Ankle Society score changed from 40 (95% CI 36 to 43) pre-operatively to 80 (95% CI 76 to 84) at a mean follow-up of 8.2 years (7 to 10) (p < 0.01). Radiolucencies were identified in up to 23% of TARs after a mean of 4.4 years (2.3 to 9.6). The mean total range of movement improved from 23° (95% CI 19 to 26) to 34° (95% CI 26 to 41) (p = 0.01).

Our study demonstrates that TAR has a positive impact on patients’ lives, with benefits lasting ten years, as judged by improvement in pain and function, as well as improved gait and increased range of movement. However, the quality of evidence is weak and fraught with biases and high quality randomised controlled trials are required to compare TAR with other forms of treatment such as fusion.

Cite this article: Bone Joint J 2013;95-B:1500–7.

The foot and ankle outcome score (FAOS) has been evaluated for many conditions of the foot and ankle. We evaluated its construct validity in 136 patients with osteoarthritis of the ankle, its content validity in 37 patients and its responsiveness in 39. Data were collected prospectively from the registry of patients at our institution.

All FAOS subscales were rated relevant by patients. The Pain, Activities of Daily Living, and Quality of Life subscales showed good correlation with the Physical Component score of the Short-Form-12v2. All subscales except Symptoms were responsive to change after surgery.

We concluded that the FAOS is a weak instrument for evaluating osteoarthritis of the ankle. However, some of the FAOS subscales have relative strengths that allow for its limited use while we continue to seek other satisfactory outcome instruments.

Cite this article: Bone Joint J 2015; 97-B:662–7.

We present the outcomes in 38 consecutive patients who had total ankle replacement using the Ankle Evolution System with a minimum follow-up of four years. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and regular standardised anteroposterior and lateral weight-bearing radiographs were obtained. Patient satisfaction and complications were recorded and the survival of the implants was demonstrated by the Kaplan-Meier method.

The mean follow-up was for 57.8 months (48 to 80). The cumulative survival rate at six years was 94.7% (95% confidence interval 80.3 to 98.7). The mean total AOFAS score was 88.1 (53 to 100). The mean score for pain was 35.8 (20 to 40). Ten patients presented with edge-loading of whom nine had corrective surgery. Two ankles were revised, one to an arthrodesis and the other to replace the tibial component. Nine patients showed radiological evidence of osteolysis. They had minimal non-progressive symptoms and further surgery was not undertaken. Nevertheless, the concerns about osteolysis led to the implant being withdrawn by the manufacturer.

The medium-term results of the ankle evolution system ankle replacement are satisfactory with high patient satisfaction, but the rate of osteolysis is of some concern. The long-term benefit of this procedure has yet to be determined.