Ankle fusion and ankle replacement - variations in surgical practice across England

T. Jennison, R. Zaidi, A. Goldberg, D. Townshend

Introduction: The definitive surgical treatment of end stage ankle arthritis is either an ankle fusion (AF) or total ankle replacement (TAR). It is anticipated that patients’ exposure to treatments differs depending on their post code and access to services. The aim of this study was to determine the variation in practice for the surgical treatment of ankle arthritis across England.

Methods: A retrospective cohort study was performed by searching hospitals episodes statistics (HES) from NHS Digital for all admissions in England between 1st April 2017 and 31st September 2022. OPCS-4.9 codes were used to determine the surgical procedure performed. Basic statistical analysis was undertaken.

Results: Overall 12,801 patients underwent surgery for end stage ankle arthritis. Of these there were 9013 (70.4%) AF and 3,788 (29.6%) TAR. Of the 9013 AF, 7034 (77.8%) were isolated AF and 1979 (15.5%) were combined with fusion of additional hindfoot joints. There was a significant variation in the proportion of AF and TAR with the ratio of AF:TAR varying more than two-fold. The number of patients that underwent surgery was 19.2% lower in 2022 compared to 2017 (2242 v 2774). Expressed as a percentage of total volume of cases, the proportion of TAR performed for end stage arthritis was significantly higher in 2022 than in 2017 (31.0% v 26.3%, p<0.001).

Conclusion: Patients with end-stage ankle arthritis are twice as likely to have an AF over a TAR. Numbers of TAR were increasing year on year but fell during Covid. Despite return to normality, the number of surgeries in 2022 have still not caught up with pre-Covid numbers. The proportion of TAR of total surgeries is increasing. Large variations in surgical practice were found based on geographical location. This data should be useful in the development of foot and ankle services nationally.