Comparisons of initial outcomes and cost-effectiveness after total ankle arthroplasty versus bipolar osteochondral allograft transplantation in the ankle: a retrospective cohort study

Abstract

Background:Total ankle arthroplasty (TAA) has been a standard-of-care surgical treatment option for patients who are suffering from ankle disorders since the 1960s. It is costly with a limited lifespan; younger, active patients will likely need additional surgeries. Evidence-based advancements in osteochondral allograft (OCA) preservation and transplantation techniques have resulted in improved outcomes, making it a potentially more appropriate treatment option for specific patients. This study compares 90-day clinical and self-reported outcomes for patients who received TAA or bipolar OCA ankle transplantation. Methods:Differences in costs and quality-adjusted life years (QALY) for patients were determined using postoperative 1-year follow-up. An institutional review board-approved review of electronic medical records and billing data was conducted for patients who underwent TAA or bipolar OCA ankle transplantation (n = 35) at a single institution between 2014 and 2018. Postoperative patient-reported outcome scores and cost comparisons were completed using a two-sample t-test, or nonparametric alternative, or chi-square test. Results:Three months after surgery, no statistically significant differences in patient-reported outcomes, postsurgical complications, or value-based care metrics were observed between older TAA (n = 18) or younger OCA groups (n = 17). Based on data, OCA and TAA were both considered cost-effective treatment options; differences in the incremental cost-effectiveness between OCA and TAA were not statistically significant (P = 0.99), and 1-year outcomes were good to excellent. Conclusions:These results will guide more robust planning for 90-day postoperative reimbursement guidelines. Ongoing work is needed to assess mid-term and long-term outcomes for patients with respect to morbidity, complications, patient-reported outcomes, costs, and QALY.

Cell-Mediated Immune Responses May Play Roles in Osteochondral Allograft Transplantation Osteointegration Failures

“…1 When successful, OCA transplantation can relieve pain and restore joint function in patients with symptomatic articular defects in the knee, hip, ankle, and shoulder. [2][3][4][5][6][7][8][9] Currently, most OCA transplantations are performed to treat large (>2 cm 2 ), full-thickness symptomatic chondral or osteochondral lesions in the knee. While recent technological advances have been associated with increased OCA availability and improved clinical success, the best current evidence supports 5-to 15-year functional OCA survival rates of 68 to 75%.…”

“…While recent technological advances have been associated with increased OCA availability and improved clinical success, the best current evidence supports 5-to 15-year functional OCA survival rates of 68 to 75%. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] As such, all components of OCA transplantation need to be further optimized to improve patient outcomes and meet the increasing clinical demand for this important treatment option for the growing number of patients affected by these complex joint problems.…”

“…Recognized factors contributing to functional graft survival after OCA transplantation include OCA-related factors (storage time, preservation methods, chondrocyte viability at the time of implantation, and preimplantation preparation and surgical techniques) and recipient-related variables (age, sex, body mass index [BMI], nicotine use, joint pathology, and patient adherence with prescribed postoperative restrictions and rehabilitation protocols) that influence cartilage integrity, rate and extent of allograft osteointegration, and joint health. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] With recent advances in tissue preservation, transplantation techniques, and patient management tools and strategies that have reportedly mitigated related modes of failure, prolonged and incomplete OCA osteointegration has become a primary mechanism for OCA treatment failure. [18][19][20][21][22] Preimplantation OCA preparation techniques, including subchondral bone drilling, thorough irrigation, and autogenous bone marrow aspirate concentrate saturation, may dampen immune responses and improve OCA osteointegration.…”