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
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
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)?
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
Results 930 Patients revision case (6) TAR->AA (5) AA->TAR (6) TTC Fusion (41) 872 Patients Included 629 TAR 243 AA
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±9.3 61.5±10.6 <0.001 57.9±11.8 52.0±12.3 0.001 BMI (kg/m2) 27.8±3.4 28.5±5.7 0.24 29.0±4.1 28.6±6.0 0.73 Follow-up (years) Diabetes (%) 4.9±2.3 5.0±2.6 0.46 3.9±1.7 4.3±2.0 0.05 21 (6.6%) 21 (6.7%) 0.97 23 (14.9%) 8 (9.0%) 0.18 Smoker (%) 17 (5.4%) 20 (6.4%) 0.59 15 (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%) <0.001 77 (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
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±10.6 40.0±11.9 30.9±10.2 37.3±12.3 p=0.001 p=0.002 35.7±11.3 42.1±13.0 32.6±10.3 39.8±14.0 p=0.05 p=0.26 SF-36 MCS Pre Post 51.6±14.1 51.2±12.7 49.1±14.8 50.1±14.2 p=0.09 p=0.02 45.8±14.9 46.6±15.7 43.8±15.0 46.9±14.6 p=0.24 p=0.91 AOS Pain Pre Post 49.9±18.6 18.8±18.3 54.5±17.2 21.5±19.3 p=0.01 p=0.04 50.7±19.2 23.0±24.1 56.8±16.3 21.9±20.1 p=0.02 p=0.61 AOS Disability Pre Post 60.6±18.2 27.5±22.4 66.1±15.8 32.8±22.7 p<0.001 p=0.003 62.4±19.4 32.1±26.6 67.9±15.2 34.8±23.9 p=0.02 p=0.60
44 Preop SF-36 PCS Postop 60 Preop Postop AOS Pain 33 45 22 30 11 15 0 Male TAR Female TAR Male AA Female AA 0 Male TAR Female TAR Male AA Female AA 70 52.5 35 17.5 0 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
Satisfaction 90 80 70 60 50 40 30 20 10 0 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 58 55 19 15 Gender had no significant impact on revision rates
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
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 15-17 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
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