Trends in the use of total ankle replacement and ankle arthrodesis in the United States medicare population

Andrew J. Pugely, Xin Lu, Annunziato Amendola, John J. Callaghan, Christopher T. Martin, Peter Cram

Research output: Contribution to journalArticlepeer-review


Background: Total ankle replacement (TAR) has gained acceptance as an alternative to traditional ankle arthrodesis (AA)for end-stage ankle arthritis. Little is known about long-term trends in volume, utilization, and patient characteristics. Theobjective of this study was to use longitudinal data to examine temporal trends in TAR and AA.Methods: We identified all United States fee-for-service Medicare beneficiaries who underwent TAR and AA between1991 and 2010 (n = 5871 and 29 532, respectively). We examined changes in patient demographics and comorbidity,nationwide and hospital volume, per capita utilization, and length of stay (LOS).Results: Between 1991 and 2010, both TAR and AA patients had modest shifts in characteristics, with higher rates ofdiabetes and obesity. Overall, TAR Medicare volume increased by more than 1000% from 72 procedures in 1991 to 888in 2010, while per-capita standardized utilization increased 670.8% (P < .001). AA volume increased 35.8% from 1167procedures in 1991 to 1585 in 2010, while per-capita standardized utilization declined 15.6% (P < .001). The percentageof all US hospitals performing TAR increased nearly 4-fold from 3.1% in 1991 to 12.6% in 2010, while the proportionperforming AA remained relatively unchanged. LOS decreased dramatically from 8.7 days in 1991 to 2.3 days in 2010 inTAR and from 5.5 days to 3.2 days in AA (P < .001).Conclusion: Between 1991 and 2010, Medicare beneficiaries undergoing either TAR or AA became more medicallycomplex. Both volume and per-capita utilization of TAR increased dramatically but remained nearly constant for AA. Atthe same time, mean hospital volume for both procedures remained low. Further research should be directed towarddetermining design, surgeon, and hospital variables that relate to optimal outcomes following TAR, which has becomeincreasingly used for the treatment of ankle arthritis.Level of Evidence: Level III, comparative series.

Original languageEnglish (US)
Pages (from-to)207-215
Number of pages9
JournalFoot and Ankle International
Issue number3
StatePublished - Mar 2014
Externally publishedYes


  • CMS
  • Medicare
  • ankle arthrodesis
  • ankle fusion
  • outcomes
  • total ankle
  • utilization

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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