Gender Differences in End-Stage Ankle Arthritis

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1 Gender Differences in End-Stage Ankle Arthritis Andrew Dodd MD, FRCSC Ellie Pinsker BA&Sc, PhD Cand. Elizabeth Jose Ryan Khan BA Mark Glazebrook MSc, PhD, MD, FRCSC Kevin Wing MD, FRCSC Murray Penner MD, FRCSC Alastair Younger MB ChB, ChM, FRCSC Timothy R Daniels MD, FRCSC

2 Disclosures No disclosures: AD, EP, RK, EJ, MG MP AY: TD: consultant/financial support: Arthrex, Biomimetic, Cartiva, Conmed/Linvatec, Integra lifesciences, Synthes, Wright Medical Board Member/Editor: AOFAS, COFAS, CORR, Foot and Ankle Specialist, JBJS Am Consultant/financial support: Wright medical, Acumed, Cartiva, Zimmer, Bioventus, Amniox, Synths Board Member/Editor: AOFAS, Foot and Ankle Int, COA Consultant/financial support: Wright medical, Carticept, Integra, Stryker

3 Background End-stage ankle arthritis (ESAA) is a debilitating disease, and its impact on quality of life is comparable to patients with end-stage hip arthritis 1 Gender differences in pre- and postoperative pain and disability have been demonstrated in the hip and knee arthroplasty population 2-6 Females have more pain, disability Few authors have investigated the clinical importance of these differences using the minimal clinically important difference (MCID) of the outcome tools used No previous studies on gender differences in ESAA Research Question Does gender influence the pre- and postoperative pain and disability of patients with ESAA undergoing total ankle replacement (TAR) or ankle arthrodesis (AA)?

4 Methods Subjects identified from Canadian Orthopaedic Foot and Ankle Society (COFAS) prospective foot and ankle reconstruction database Inclusion: All patients undergoing primary TAR or AA for ESAA of varying etiologies with minimum 2-year followup Exclusion: <2 years followup, tibiotalocalcaneal (TTC) fusions, revision TAR or AA, conversion of TAR->AA or AA->TAR Outcomes: Primary: Ankle Osteoarthritis Scale (AOS) measure of pain and disability (function) specific to ankle arthritis Short Form-36 Health Survey Secondary: Generic health outcome tool with both physical (PCS) and mental (MCS) components Patient satisfaction (Foot and Ankle Follow-up Questionnaire) Revision rates

5 Results 930 Patients revision case (6) TAR->AA (5) AA->TAR (6) TTC Fusion (41) 872 Patients Included 629 TAR 243 AA

6 Demographics Total Ankle Replacement Ankle Arthrodesis Male (n=316) Female (n=313) P-Value Male (n=154) Female (n=89) P-Value Age 65.4± ±10.6 < ± ± BMI (kg/m2) 27.8± ± ± ± Follow-up (years) Diabetes (%) 4.9± ± ± ± (6.6%) 21 (6.7%) (14.9%) 8 (9.0%) 0.18 Smoker (%) 17 (5.4%) 20 (6.4%) (9.7%) 10 (11.2%) 0.71 Etiology (%) Post-Traumatic Primary Rheumatoid Other IA Other 184 (60.1%) 90 (29.4%) 25 (8.2%) 5 (1.6%) 2 (0.7%) 171 (56.6%) 61 (20.1%) 65 (21.5%) 6 (2.0%) 0 (0.0%) < (52.7%) 54 (37.0%) 3 (1.9%) 4 (2.7%) 8 (5.5%) 51 (60.7%) 17 (20.2%) 7 (8.3%) 7 (8.3%) 2 (2.4%) 0.01

7 Outcome Scores Total Ankle Replacement Ankle Arthrodesis Male (n=316) Female (n=313) Sig. (2- tailed) Male (n=154) Female (n=89) Sig. (2- tailed) SF-36 PCS Pre Post 33.6± ± ± ±12.3 p=0.001 p= ± ± ± ±14.0 p=0.05 p=0.26 SF-36 MCS Pre Post 51.6± ± ± ±14.2 p=0.09 p= ± ± ± ±14.6 p=0.24 p=0.91 AOS Pain Pre Post 49.9± ± ± ±19.3 p=0.01 p= ± ± ± ±20.1 p=0.02 p=0.61 AOS Disability Pre Post 60.6± ± ± ±22.7 p<0.001 p= ± ± ± ±23.9 p=0.02 p=0.60

8 44 Preop SF-36 PCS Postop 60 Preop Postop AOS Pain Male TAR Female TAR Male AA Female AA 0 Male TAR Female TAR Male AA Female AA Preop Postop AOS Disability Male TAR Female TAR Male AA Female AA Females had worse pain and disability preoperatively for both TAR and AA Females had worse pain and disability postoperatively for TAR No differences seen postoperatively for AA

9 Satisfaction Male TAR Male AA Female TAR Female AA Expecta:ons Sa:sfac:on TAR patients had higher expectations preop, but equivalent satisfaction postop Male TAR patients more satisfied postop than male AA patients Revisions Total Ankle Replacement Ankle Arthrodesis Male Female Male Female Gender had no significant impact on revision rates

10 Discussion Statistically significant differences in preoperative pain and disability, with females having worse outcome scores. Differences persisted postoperatively in the TAR group but not the AA group. Possible Explanations: Arthritis etiology: larger number of inflammatory arthritis patients in female TAR group Inflammatory arthritis affects outcomes 7 Females tend to delay arthroplasty surgery longer than males 8 Preoperative pain/function has large impact on postoperative pain/ function 2,3,9,10 Gender differences in pain perception/behavior 11,12

11 Discussion Clinical Relevance? In large studies, small differences between groups become statistically significant 13,14 The differences between groups in our study do not meet the minimal clinically important difference (MCID) of the outcome instruments used Patient Counselling This information is valuable when discussing surgical options with patients preoperatively Males and Females both improve substantially after TAR and AA Females have worse outcome scores than males after TAR Satisfaction rates are similar between the two procedures TAR patients have higher expectations than AA patients Males TAR patients are more satisfied postoperatively than Male AA patients

12 References 1. Glazebrook, M., et al. (2008). "Comparison of health-related quality of life between patients with end-stage ankle and hip arthrosis." J Bone Joint Surg Am 90(3): Singh JA, Gabriel S, Lewallen D. The Impact of Gender, Age, and Preoperative Pain Severity on Pain After TKA. Clin Orthop Relat Res. 2008;466(11): Ritter MA, Wing JT, Berend ME, Davis KE, Meding JB. The Clinical Effect of Gender on Outcome of Total Knee Arthroplasty. The Journal of arthroplasty. 2008;23(3): Holtzman J, Saleh K, Kane R. Gender differences in functional status and pain in a Medicare population undergoing elective total hip arthroplasty. Med Care. 2002;40(6): Petterson SC. Disease-Specific Gender Differences Among Total Knee Arthroplasty Candidates. The Journal of bone and joint surgery American volume. 2007;89(11): Hawker GA, Wright JG, Coyte PC, et al. Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med. 2000;342(14): Pedersen E, Pinsker E, Younger ASE, et al. Outcome of Total Ankle Arthroplasty in Patients with Rheumatoid Arthritis and Noninflammatory Arthritis: A Multicenter Cohort Study Comparing Clinical Outcome and Safety. J Bone Joint Surg Am. 2014;96(21): Karlson EW, Daltroy LH, Liang MH, Eaton HE, Katz JN. Gender differences in patient preferences may underlie differential utilization of elective surgery. Am J Med. 1997;102(6): Kennedy DM, Hanna SE, Stratford PW, Wessel J, Gollish JD. Preoperative Function and Gender Predict Pattern of Functional Recovery After Hip and Knee Arthroplasty. The Journal of arthroplasty. 2006;21(4): Lingard EA, Katz JN, Wright EA, Sledge CB, Kinemax Outcomes Group. Predicting the outcome of total knee arthroplasty. The Journal of bone and joint surgery American volume. 2004;86-A(10): Keefe FJ, Lefebvre JC, Egert JR, Affleck G, Sullivan MJ, Caldwell DS. The relationship of gender to pain, pain behavior, and disability in osteoarthritis patients: the role of catastrophizing. Pain. 2000;87(3): Jensen I, Nygren A, Gamberale F, Goldie I, Westerholm P. Coping with long-term musculoskeletal pain and its consequences: is gender a factor? Pain. 1994;57(2): de Vet HC, Terwee CB, Ostelo RW, Beckerman H, Knol DL, Bouter LM. Minimal changes in health status questionnaires: distinction between minimally detectable change and minimally important change. Health Qual Life Outcomes. 2006;4: Coe MP, Sutherland JM, Penner MJ, Younger A, Wing KJ. Minimal Clinically Important Difference and the Effect of Clinical Variables on the Ankle Osteoarthritis Scale in Surgically Treated End-Stage Ankle Arthritis. J Bone Joint Surg Am. 2015;97(10): Pinsker E, Inrig T, Daniels TR, Warmington K, Beaton DE. Reliability and Validity of 6 Measures of Pain, Function, and Disability for Ankle Arthroplasty and Arthrodesis. Foot Ankle Int. 2015;36(6): Escobar A, Quintana JM, Bilbao A, Aróstegui I, Lafuente I, Vidaurreta I. Responsiveness and clinically important differences for the WOMAC and SF-36 after total knee replacement. 17. Quintana JM, Escobar A, Bilbao A, Aróstegui I, Lafuente I, Vidaurreta I. Responsiveness and clinically important differences for the WOMAC and SF-36 after hip joint replacement. Osteoarthritis and Cartilage. 2005;13(12): Osteoarthritis and Cartilage. 2007;15(3):

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